Accountable Care Organization

Episode 48: Reducing Unwarranted Care Variation

May 2023

Reducing care variation is a strategic goal for both the MaineHealth ACO and the MaineHealth system during FY24 and beyond. The ACO’s chief operating officer, Shannon Banks, joins us to introduce initiatives that the ACO board has approved for addressing unwarranted variation in end-of-life care and transitions of care.

Heather: This is BACON, brief ACO News from the Maine Health Accountable Care Organization. A nose-to-tail, no-waste monthly podcast for health care providers. I'm Heather Ward.

Mike: And I'm Mike Clark. Heather and I are practicing physicians who participate in the MaineHealth ACO.

Heather: In this episode, we address care variation reduction, a relatively vague health care term that's driving a lot of activity at the ACO and MaineHealth.

Mike: So, Heather, let's clear up that vagueness and explore what care variation reduction is, and how it will play out at the ACO and MaineHealth in the months and years to come.

Heather: Let's get to it.

Mike: Okay. So, Heather, let's start with some basics. If you research the term, quote, care variation reduction, unquote, you'll quickly learn that it's short for unwarranted care variation reduction. And according to leading health care researcher John Wennberg at Dartmouth, unwarranted care variation can be defined as variation in the utilization of health services that cannot be explained by variation in patient illness or patient preferences.

Heather: Okay, Mike, that's a lot. Let me try to paraphrase. Basically, there are variations that exist for some reason other than what's best for the patient. Is that too bold?

Mike: Well, that's kind of provocative way to simplify it, but I really think it's on the right track. I mean, let's face it, unwarranted variation is not some egregious practice by an unscrupulous doctor. It exists for a lot of reasons. There may be outmoded workflows or personal preferences that are unsupported by evidence or even a lack of clear and consistent protocols. But reducing these can definitely have positive implications for patient outcomes.

Heather: And for controlling costs as well. Makes total sense that the ACO and MaineHealth are interested in this concept.

Mike: Yep. Especially considering the value-based care payment model we're working in, which is designed to reward both positive patient outcomes and lower total cost of care.

Heather: Yeah. Okay. Let's bring in our guest for this topic Shannon Banks. Shannon is the chief operating officer of the MaineHealth ACO and the co-chair of the Maine Health Systems Care Variation Reduction Steering Committee. Say that three times fast.

Mike: I'll let you say it three times fast.

Heather: Shannon spoke to our producer, Paul Santomenna, about exactly what initiatives are being planned with the ACO participants to reduce variation.

Paul: So you're helping to lead a committee on this topic, a system wide committee with, I believe, Doug Sawyer, the acting CMO, is the the co-chair with you. So what is the work of that committee? How is that acting upon the mandate here?

Shannon: So, the committee's job is to review and provide input to- and approval of- priorities, goals, measures and targets that support the MaineHealth strategic objective regarding care variation reduction.

Paul: So at the ACO, Shannon, there's work being done, very specific work being done on this as well. Can you talk about that?

Shannon: Yes, I'm happy to. And and I'm happy to say the ACO, of course, has been paying attention to the drivers of value in our value based contracts for years. And we have had significant maturity in our ability to reduce variation in the delivery of quality and in driving appropriate documentation of care. Those are two areas where we've seen significant gains in past years. And you know, you can think about those areas as having possibilities for variation. If there's variation in performance around the way we close gaps in care for certain quality metrics, that counts as variation just as much as the variation we might see in an orthopedic surgery unit using a wide variety of devices, for instance. But we've got a pretty good track record with quality and with accurate documentation. A new frontier for us is focusing more closely on issues around utilization and cost. And the Value Oversight Committee of the ACO has been for months preparing to sort of shift itself into high gear in reviewing cost and utilization. And in fact, we redesigned the Value Oversight Committee with the express purpose of doing that. And this seems to line up very nicely with the system's decision to adopt a care variation reduction objective. In turn, the MaineHealth Steering Committee on care variation reduction asked the Value Oversight Committee of MAKO to lead efforts on care variation reduction for the ambulatory side of the organization. So, we've spent several months researching possible areas of intervention. We've been we've been fortunate to be able to lean on our Arcadia platform for an analysis of both claims and clinical data to understand where those opportunities are.

Shannon: We've been partnering with clinical leaders in various clinical areas to get their guidance on how to interpret the data and how to design the analysis so we could see where there were real opportunities. And we've landed on two areas of focus that we've recommended be adopted for 2024 effort by the system. We've identified end of life care as one critical area for focus, and the second is called transitional care management. And I'm happy to tell you a little more about each of those if you'd like me to get into some detail.

Paul: Yes. Okay. Yeah.

Shannon: So, with regard to end-of-life care, what we've identified as a metric to pay attention to is, is days in hospice or adequate use of hospice. And it turns out that patients who have adequate use of hospice enjoy better end to their lives and their families also experience that as well, as well as having a reduced cost of care at the end of their lives. And so, we also see significant variation in the way patients experience the end of their lives within the Maine health system. So, for instance, we see up at Mid Coast Hospital a higher proportion of patients getting adequate hospice care at the end of life. And we think that reflects an investment on the part of MidCoast into palliative care services that have been available to that community in a way that they have not been to other communities in our system. So the goal is to increase the proportion of patients who get adequate hospice at the end of life.

Paul: And give us a quick overview of the transitional care management.

Shannon: Sure. So transitional care management refers to the kind of care a patient might get after being discharged from the hospital. And I think we all know that seeing your provider shortly after discharge is associated with better health outcomes and a lower likelihood of readmission to the hospital. What we now know is that not just seeing your provider, but having the specific kind of visit called a transitional care management visit, is associated with better outcomes and lower readmission. So, there are some nuances to how you conduct a transitional care management visit. And it includes a call from a nurse, it includes med reconciliation, and not all of our patients are today getting that TCM visit even though it might be appropriate for them. So again, this is an area where we see wide variation throughout the system. Reducing that variation will require some operational interventions, new care pathways, support from care managers, and changes in the way our practices manage patients who have been discharged from the hospital. But we know that an improvement in this area can significantly improve health outcomes for patients and substantially reduce the likelihood of readmission.

Paul: So of course, this is all being planned for FY 24, which doesn't start until October. But I'm sure there are many steps being taken right now. So what are the what's what are the next steps? What's happening now around these two things?

Shannon: Yeah, lots of kind of organizing. We've spent, you know, the previous several months analyzing the data and teeing up the issues and kind of lobbying and educating stakeholders about the importance of these issues. We've now gotten endorsement and support for moving ahead. That's terrific. But there's an awful lot of kind of socializing of the messages to do, educating stakeholders about what this might mean for them, how this might how this might change priorities on the balanced scorecards at local health systems, for instance. The ACOs role in that will be, I'll call it, supporting the operational leaders who will take on leading this work by ensuring that we have surveillance, monitoring of the performance on these two areas, and so that we can support interventions by saying, "Hey, here's what your trended data looks like, here's where you're we're seeing success or challenges in towards the targets we've identified for these two areas." We were also convening stakeholders to clarify next steps in operationalizing. So it's not really the ACOs job to execute on the operations, but we find ourselves being a convener of stakeholders such as Becca Hutchinson, data analyst from the ACO and from the oncology units, bringing together oncologists and primary care doctors for conversation about the issues and just generally teeing up the work and then monitoring the performance along the way.

Paul: Well, thanks, Shannon. Thanks for filling us in. I'm sure we're going to hear a lot more about both end-of-life care and transitions of care from the ACO and the system and elsewhere over the next couple of years, probably.

Shannon: I think so. I think it'll be a multi-year effort and I'm excited about it because I really do think that we've got a lot of momentum towards towards this goal of reducing variation in care. We're going to see energy and attention on this. And generally when you've got energy and attention, you get improvement, which will be great for health outcomes and also great for our success and our value based contracts. And something else I might mention is that the ACO and the Care Variation Steering Committee are co-hosting a Care Variation Reduction Summit coming up in June, and this will be an invitation only event, but it will bring together 50 or 60 clinical and business leaders who are heavily involved in care variation reduction efforts to share what they're learning and energize one another around these efforts. So looking forward to that event as well.

Paul: Great. Well, thanks so much, Shannon.

Shannon: You're welcome, Paul.

Mike: So thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, And if you have questions, comments or suggestions, we really would love to hear from you. Please email us at That's

Heather: Bacon is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.

Mike: See you next time.