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Episode 34 – February 2022: ACO Performance & Operational Update

February 2022

MaineHealth ACO Chief Operating Officer Shannon Banks shares new performance results and introduces a sophisticated new data analysis report. Also, Ansar Hassan, MD, on MMC's Mitral Center of Excellence.

Additional Info

Mitral Center for Excellence referrals:

Epic: refer to heart valve program

207-661-MTRL (6875)

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, a hard-boiled monthly podcast for health care providers. I'm Julie Grosvenor.

Mike:
And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: This month, we will talk to Dr. Ansar Hassan about Maine Medical Center's new Mitral Center of Excellence.

Mike: That sounds very interesting, but first, we take a deep dive into the inner workings of the ACO with an operational and performance update from Shannon Banks, our own chief operating officer.

Julie: That sounds great.

Meaty Topic…

Julie: It's been a while since we checked in with the ACO directly about its performance and operations. So, for our Meaty Topic this month, Mike talks to Shannon Banks, the ACO's chief operating officer, to understand how the ACO is doing, how its operations are evolving, and what we can expect down the road.

Mike: So, Shannon, thank you for joining us here at the BACON podcast to give us an update on ACO, especially as we settle the 2020 contract year.

Shannon: Hey, Mike, nice to be here.

Mike: So let's dive right in. The ACO recently settled its 2020 value-based contracts. We're really hoping that you could give us an overview of how we performed on those.

Shannon: I am thrilled to give you an overview, especially because we had our best financial performance year ever, Mike, and we are settling our contracts for 2020 to the tune of $26 million, and that's a combination of shared savings and pay-for-performance earnings coming to the ACO, which will of course in turn be distributed to participants.

Mike: Wow, so that's incredible, that's a big number. Now, how does that compare to prior year's performance?

Shannon: Good question. And it's just shy of $10 million more than last year's performance and about $14 million more than the preceding year. So we seem to be on an upward trajectory right now, and we're really proud of that.

Mike:
That's great. Great news. So what key factors led to the performance we saw?

Shannon: Well, thanks for asking. You know that we think about our value-based contracts as being driven by three major categories of drivers. One is quality, and we often ask our participants to focus on the quality top 10, for instance, how do we perform in the heat map, which everyone is so familiar with. And we know that a couple of the measures on that heat map, which really contributed favorably to our results, were breast cancer screening and med adherence measures, but also ED utilization. ED Utilization was likely suppressed somewhat due to COVID during this performance period. But that, in turn, was a favorable quality performance. We also know that speaking of suppressed utilization, that COVID did depress utilization during performance year 2020, and that probably favorably impacted the total cost of care. So, we benefited from that. Of course, that will raise questions about are folks getting the care they need, and that's something for us to keep an eye on going forward. Finally, the third driver of value-based performance would be accurately representing the health of patients through appropriate coding, and we know that our 2019 risk capture favorably impacted our 2020 contract performance.

Mike: Wow, that's great news. So to our physician audience, all of that training that they sat through and all that hard work to try to improve the specificity and accuracy of their coding really did translate into improvement in our contract performance. That's great to hear.

Shannon: It really did. It really did. Yeah, we're delighted to see that.

Mike: Terrific. So I know that the ACO is constantly adapting to meet the shifting needs of both participants and payers. So what's new at the ACO from an operational standpoint?

Shannon: Well, something that is exciting to me and I think is probably worth talking to this audience about is that the ACO has recently been building some new analytic products, which we are sharing with our local health systems. We call this the value-based opportunity report or VBOR for short. And not only is the analytic product really interesting, where it shows detail by local health system about their performance and quality and utilization and documentation, but those reports are not simply emailed or dropped on someone's desk. We deliver that analytic report in the context of a leader-to-leader meeting. So, Jen Moore and Rob Chamberlin, and I get together with the local health system president and CMO and CFO, and anybody interested on the part of that local health system to review the data and be in dialogue with them about their particular performance and opportunities. And I'm just really proud of this analytic report that we've built and having an awful lot of fun talking with the leaders out of the local health systems about their performance and finding that they're very interested. When you can offer data that is specific to their situation, it drives a really interesting dialogue.

Mike: What lies ahead? What's sort of top of mind, as we're still early in 2022 and thinking about where the wind is blowing as far as value-based care and the ACO's leadership within our system?

Shannon:
Well, thanks. You know, I think those three drivers that I'll probably talk about every time we chat remain important. So, continuing to focus on the top 10 quality metrics, on reducing unnecessary care, you know, avoidable ED visits or avoidable admissions, will remain important, and continuing to document well will remain important. One thing that we're conscious of, having just settled the 2020 performance year, we're conscious that it was 2019 coding that led to our financial performance being better than the benchmarks against which we are compared. We also know that 2020, we didn't have such a strong year in coding and that had to do with COVID. And so the question remains, how will our performance compare to benchmarks? We still don't know how others performed in 2020, so it remains to be seen whether that will have a negative effect on our earnings in 2020 or not. So that's just something that we're keeping an eye on, but it remains important to keep capturing those codes. 2021 documentation will impact 2022 earnings and so on, and so on. So it's a constant battle.

Mike: So, Shannon, one more question for you before we conclude. When we talk about earnings on or shared savings in our value-based contracts, what does that mean? How should we think about that?

Shannon:
The ACO earns shared savings when it manages the total cost of care to a figure lower than was budgeted for the population, and in 2020, we did that very well. And that means that the ACO and its participants get to retain some of the savings between the budgeted figure and the actual figure. Now, I think what you might also be asking Mike, is what happens to them. So $26 million that the ACO earned for its 2020 performance sounds like an awful lot of money. Where does it go? Who experiences the savings and what happens with that money that's earned by the ACO? And I'll talk a little bit about the savings because it really reflects savings to the community as a whole, it reflects lower cost of care for patients and for the community. And we've basically lowered the medical expense curve or trend in our community by reducing the cost of care in this way. The earnings that come to the ACO or part of it comes to the ACO, part of it, of course, is shared by the payer. The ACO's portion is distributed to its participants by and large, and the participants can decide to do what they will with it. Most often, in some way, it is redirected towards patient care, and many times it's redirected towards transitioning our care delivery system to be organized in a way to deliver value versus volume. And I realize I'm using a lot of jargon, and Mike you're a PCP, maybe you could talk a little bit about, as a participant, what does it mean to you?

Mike: Yeah, I was just thinking about that in, you know, as a primary care doc, sometimes I feel like my best work is non-billable. You know, seeing somebody, working somebody in who might otherwise be sent to the emergency room for a higher cost of care, or handling something over the phone, or staying late to manage my patients with whom I have this relationship. A lot of those things are not, you know, not billable, and yet, have tremendous value as far as to the patients, to their experience of care, hopefully to their health outcomes. So when I get, when my practice gets its share of shared savings, I think of that as a way to help pay for that extra attention to our patient population that I can't submit on a claim form. And that helps us to stay healthy as a practice and be able to really not be focused on just widget making, so to speak. Patients cranked through the practice, but really focusing on taking care of our population of patients. So it means a lot to me as a small practice owner.

Shannon: Right. That's great to hear.

Mike:
Thank you. And thank you so much for all of the work that you and the leadership team there, and all of your folks at the ACO do to keep all of our practices healthy and successful as we transition to more of a value-based health care system.

Shannon: Great to chat with you, Mike.

The Sizzle…

Julie: For the sizzle this month, we talked to Dr. Ansar Hassan about a new Center of Excellence he's part of at Maine Medical Center. It's focused on treating mitral valve disease with a specially trained interdisciplinary team.

Mike: Yes, and our producer Paul Santomenna, talked to Dr. Hassan last month.

Paul: Ok, Dr. Hassan, start us off with some background on the mitral valve program.

Ansar: The Mitral Center of Excellence was really started with a view to concentrating our expertise in the area of mitral disease and to be able to offer patients with mitral disease the best interventions possible, the best outcomes possible. The focus, I think of the Mitral Center of Excellence is really on patients with mitral regurgitation and structural disease. And by that, I mean, people who have got mitral regurgitation secondary to disease, such as a flail mitral valve leaflet or prolapse leaflet, a cleft. But it's definitely not limited to that per se. And I would highly encourage anybody who has a patient with mitral disease to send their patient, regardless of what the etiology is. But having said that, you know, when we look at mitral disease and what's being offered out there today, from optimized medical therapy to advanced surgical therapies by way of mitral repair, both done as traditionally and minimally invasive, and of course, interventional approaches. So I'm speaking specifically to the MitraClip procedure, which is done percutaneously. There's a lot of options for patients out there. And so it often requires a multidisciplinary approach to identify what the best interventions are so that their outcomes are as optimized as possible. So I think hence the background to the Mitral Center of Excellence and why it is that we've put together a group of colleagues that have the mitral valve as their area of interest. So we're excited. I think the Center of Excellence has a lot of potential and we'll get into some of this later on in the podcast. But I think has a lot of potential and I think it would be a great way for patients across the state of Maine to be looked after in the best way possible.

Paul:
Great, yeah, tell us what it means to be a center of excellence, and also, I understand the program's a member of the Cardiothoracic Surgical Trials Network? So just talk about those things a little bit more and what that means.

Ansar: Yeah, so I mean, we've referred to the Mitral Center of Excellence as such because we feel like it's about excellence of care. We're technically a regional center of excellence. I think in the state of Maine, we definitely would like to think of ourselves as being the place that offers the most comprehensive care possible for these patients so that they're looked after from top to bottom and given every choice possible with respect to their mitral disease. And I think what's nice about being a center of excellence is that you, not only sort of, I guess, announce what it is that you hope to deliver, but patients have an expectation of what they're going to be offered and how they're going to be looked after. And I think it's a nice sort of arrangement. It's almost an agreement, so to speak, that if you come here, we'll make sure that we've looked after you in every way possible. As far as the Cardiothoracic Surgical Trials Network is concerned, the CTSN is a trials network formed by some of the top cardiac surgical minds across the country, and the world for that matter, and many excellent trials have been done by this particular organization, not all necessarily related to the mitral valve, some related to other things. We've been a part of the CTSN now for many years. There was the last mitral valve study that was done officially and published in the New England Journal of Medicine looked at mitral valve repair versus replacement in the setting of what's called ischemic mitral regurgitation. So I think by being a mitral center of excellence, we position ourselves well to be an active part of such a trials network so that we're no longer just simply looking at the data that they produced and the publications that they produce. No, we're a part of these studies now, and we can be a part of a trial that would, for instance, look at one repair technique versus another or repair technique versus the MitraClip. There's a lot of potential there, and the center of excellence once again positions ourselves well with respect to some of these types of large organizations.

Paul: You mentioned that one of the things that distinguishes this center is the interdisciplinary nature of the team. Can you talk about that?

Ansar: Yeah. So there's multiple players involved. And I mean, it starts at the level of the nurse and the nurse practitioners who see these patients and are really integral to the management of patients within the valve clinic. Then we kind of move into the physician realm, and we often will have, and any patient encounter, we'll have three physicians involved. We'll have a surgeon, we'll have the interventional cardiologist and then we'll have a clinical cardiologist whose expertise really is also the echocardiogram, and being able to read and interpret the echocardiogram. So now you have somebody who is able to do a surgical repair, you have somebody in the room who's able to offer the MitraClip and then you have somebody who is able to really kind of help balance the discussion and speak to optimal or guideline-directed medical therapy, but also speak to the echocardiogram, specifically, and say, Hey, you know what? These are what options exist for this patient. So, from my standpoint, having those three people in the room really kind of feeds into the shared decision-making model that exists now, where patients are being offered all of the information. Are not necessarily being asked to make the decision on their own. Rather, they're being asked to make the decision in concert with us with the data in hand. And that's a typical sort of patient encounter. Yeah, it's a little bit longer than your average patient encounter, but I think it's more thorough and comprehensive, and I think a patient leaves that feeling that they've been seen by everyone that this isn't a biased approach that the surgeon really just wants to operate on them because that's what they do best or that the interventional is just wants to offer them a clip because that's what they do best. No, we're all in the room and I think we come out of there with some kind of harmony as to what it is that we think is the best option possible.

Paul: And your particular area of focus is in minimally invasive procedures, right? And you've just joined the center in the last couple of months. So tell us about your work and how that's expanding or changing what's available there.

Ansar: Yeah, thanks. Look, I was fortunate after my residency in cardiothoracic surgery to go and do a fellowship and minimally invasive cardiac surgery and robotic cardiac surgery with Dr. Randolph Chitwood and East Carolina University in Greenville, specifically North Carolina. And he was really the world expert in minimally invasive mitral surgery. Actually, his center is the one that gained the FDA approval for the robot in the field of mitral disease. So I kind of gained a lot of my knowledge and expertise during my two years with him and was able to take that back to the center that I was at previously, which was the New Brunswick Heart Center in St. John, New Brunswick, which is in Canada. So as a Canadian, I spent the last 12 and a half, 13 years in New Brunswick kind of honing my craft and building the minimally invasive program there. And what we noticed in New Brunswick was two things, number one was that as you did more these procedures, you got increasingly adept such that the operative times went down the outcomes seemingly got better. The willingness to take on more challenging cases went up as well. The second thing also was that you noticed that there were patients that were now being referred to you that clearly were not being referred to you previously because there was a minimally invasive approach and by minimally invasive I'm talking about a five to seven-centimeter anterolateral thoracotomy approach through the fourth intercostal space with a separate small incision in the groin for cannulation purposes. So, people who had asymptomatic mitral disease who may have been sat upon before because they really did not want to go through a sternotomy-based cardiac surgical procedure, these patients were now being referred to us. And those two things are things that I feel are important to the growth of any minimally invasive program. Coming now here to the Maine Medical Center, I'm excited. I'm excited to bring that expertise with me and to help continue to grow the program here. I'd be remiss if I didn't mention Dr. Reed Quinn, who is one of our mitral experts here. One of the cardiac surgeons who has started doing minimally invasive surgery here and is actually one of the pioneers and some of the mitral valve repair techniques that we have at our disposal. So I will be working with him, and the two of us really will be spearheading this minimally invasive program with a view to eventually introducing robotic cardiac surgery and specifically robotic mitral valve surgery here at Maine Med in the next year or so.

Paul: And finally, if a provider wants to refer patients, you know, what type of patient would be eligible and how do they do that?

Ansar: You know, if you have a patient with mitral disease that you want to have assessed at whatever stage of their workup, you know, the two options are as follows. One is through the Epic program itself, so you can send a referral to the heart valve program. That's number one, and number two is just simply a phone number 661-MTRL, and we'll make sure we put that down for people to see. But yeah, those are the two best ways to kind of get into the mitral clinic. One through Epic and one through 661-MTRL. And yeah, we'll be happy to see anyone. Having said that, obviously, I mean, as I said earlier, the focus is a little bit on structural disease and people, regurgitation and mitral disease. But nevertheless, I don't think we're at a point where we're restricting access to this particular mitral clinic.

Paul: Great. Ok, well, thanks for taking the time.

Ansar: Thanks, Paul. Appreciate the time and looking forward to speaking with our collaborators from across the state.

Julie: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you, really. So please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Mike: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. We'll see you next month.

Julie: See you next month.