Medicare groups provide quality care, save money in high-cost Nebraska

OMAHA -- More than a half-dozen years ago, doctors and hospitals in Nebraska began forming groups with the goal of taking very good care of older adults enrolled in a federal Medicare program.

If they met the marks set by Medicare's shared savings program, the so-called accountable care organizations could not only improve their patients' health but also reduce costs.

According to Medicare's latest stats from 2021, the seven Nebraska accountable care organizations that participate in the program all performed better than the national average on most patient satisfaction and quality measures.

The measures include:

* Limiting the number of patients readmitted to hospitals

* Making sure patients get flu shots and cancer and depression screenings

* Getting patients to attend annual well visits and keeping their diabetes and high blood pressure under control

As a result, six of the seven netted combined savings of $40.3 million for 2021 over Medicare's spending targets. That earned them a share of those savings from the federal Centers for Medicare & Medicaid Services. Nationally, the program saved Medicare $1.66 billion in 2021, according to federal officials, with approximately 58% of accountable care organizations earning payments.

"It literally cost less, and at the same time, the care they got was better," said Dr. Bob Rauner, chief medical officer for Lincoln-based OneHealth Nebraska, who crunched the Nebraska accountable care organization results with health data analyst Ted Fraser. "It's like getting leather seats but paying less for the car ... And, oh, by the way, the customer service was pretty good, too."

The results come as older Americans enter into Medicare's open enrollment period, the one time of the year when they can join, switch or drop a plan and change drug coverage or Medicare Advantage plans for the coming year. The period runs through Dec. 7.

And the results have both the federal government and some local health officials wanting more.

Centers for Medicare & Medicaid Services has set a goal of having 100% of people with traditional Medicare in an accountable care relationship by 2030.

And in Nebraska, a group, spurred by the success of the model, has launched an initiative called ALIGN — or, alternatively, Nebraskans for Better Health — that's working to take a similar approach on a broader scale.

Spearheaded by Rauner and Dr. Ali Khan, dean of the University of Nebraska Medical Center's College of Public Health, the group has agreed upon 11 health quality measures for adults, children and pregnant people that data show can have a significant impact on health and health care costs across large numbers of people. They're also measures for which successful interventions are available to make them happen.

The measures include some of those used by accountable care organizations in the Medicare program, including controlling patients' diabetes and high blood pressure and making sure they complete cancer screenings. But the group added measures for immunizations and well visits for kids and adolescents, prenatal and postpartum care for pregnant people and screenings for depression and unhealthy alcohol use.

"This is our belief, that if we get these done we can have improved health within the community," Khan said.

The next step, he said, will be to reach out to employers across the state and ask them to require their insurers to provide them with anonymous annual data on the outcomes for those measures among their employees.

The group, Khan said, also would ask employers to share with the group that deidentified data, which insurers already collect, so members can use it to compare and drive improvements in quality across the state, just as accountable care organizations do with their internal data.

The group includes representatives of health systems, insurance companies, the Nebraska Department of Health and Human Services, some local health departments, Medicaid providers and other organizations.

If the initiative works, Khan said, employers will have healthier employees and lower health care costs.

Nebraska came in at No. 9 among states in standardized per-person health spending in 2019, when adjusted by age, sex and other factors, according to estimates in an August report in the journal Health Affairs. The state also had the seventh highest out-of-pocket spending. The U.S. has the highest per-person health spending in the world.

"This really has to be driven by employers," said Khan, who stressed that the initiative won't cost employers extra. "We have good insurance companies and good health systems, and they want to make people healthier. They're fighting for every patient in the state when they have these conversations."

Said Rauner, "We're doing really well in the Medicare population. Now we just need to do the same in our not-Medicare population."

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The state's accountable care organizations are part of an effort to shift from a "fee-for-service" model, in which doctors are paid for each service or procedure, to a "value-based" system. Under that system, physicians instead agree to provide coordinated, high-quality care for patients, typically in return for an opportunity to share in savings. Some accountable care organizations also agree to repay Medicare if they miss their goals.

Medicare's shared savings program now is one of the largest value-based programs in the country, according to federal officials

As of January, 483 accountable care organizations were serving more than 11 million people with Medicare, according to the National Association of Accountable Care Organizations.

The organizations typically encourage patients to develop relationships with primary care doctors who work alongside other health professionals, including health coaches and care coordinators, to manage chronic conditions such as diabetes and heart disease so patients don't wind up in emergency rooms or hospitals.

The average cost of care for the seven Nebraska accountable care organizations serving Medicare patients last year was $10,494. That was $402 less than the national average.

Patients don't necessarily know whether they're part of accountable care organizations; they're enrolled based on the provider they see. The seven accountable care organizations now based in Nebraska together cover more than 111,000 Nebraskans enrolled in traditional Medicare.

Meanwhile, some accountable care organizations also have similar arrangements with commercial insurers, such as Blue Cross Blue Shield of Nebraska, and with Nebraska Medicaid and insurers participating in the federal Medicare Advantage program, a private-sector alternative to traditional Medicare.

Blue Cross, for instance, has nearly 218,000 members covered by commercial plans that are attributed to accountable care organizations.

Lee Handke, CEO of the Nebraska Health Network, said its accountable care organization now has 15 different value-based agreements covering 215,000 people, up from just a few when it started. Such arrangements have become more the norm than the exception over the past decade.

The network, which was one of the six to earn Medicare savings, includes doctors and hospitals from Nebraska Medicine, Methodist Health System and Fremont Health.

Under its Medicare contract over the past five years, the organization has seen strong improvements in rates of hospitalization, which are down 22%. Emergency department visits are down 18% and discharges to skilled nursing facilities decreased 26%.

Handke said he thinks more progress can be made. One thing driving success is the availability of data analytics. Network staff can tap claims data as well as clinical records, which gives clinicians a better view of their patients and their needs and enables better care.

The network works with clinicians, largely health coaches, to identify gaps in care, such as diabetic patients who haven't been to the clinic for a while. They also use data to identify patterns of care that result in better outcomes so they can share that across clinics.

Dr. John Findley, president of Bryan Health Connect, said Nebraska stands out as a high performer in the program. The accountable care organization, in its second full year in 2021, increased its savings rate and generated $6.8 million in savings last year.

That speaks to strong support from the health system's leaders and a commitment by primary care providers to build a team to get the work done, he said. Most members are reinvesting their savings under the program, hiring staff needed to coordinate patient care and upgrading technology needed to track health metrics.

While Bryan Health Connect is based in Lincoln, more than half of its members live in rural areas. That poses a challenge because small rural hospitals are reimbursed differently by Medicare than larger ones, which impacts their numbers, Findley said. But in a primarily rural state, the commitment to rural health care is important. The accountable care organization's 100% quality score means more Medicare beneficiaries got preventive care such as colonoscopies and mammograms.

Bryan Health Connect also is in agreements with other insurers, including Nebraska Medicaid, Findley said. The group also is involved in the ALIGN initiative and is interested in bringing it to employers.

NPG Health Collaborative, managed by Prairie Health Ventures, was the one Nebraska Medicare accountable care organizations that did not achieve savings in 2019. However, the group scored well on quality measures, said Rodney Triplett, Prairie Health's CEO.

The other Nebraska-based Medicare accountable care organizations are CHI Health Partners, Midwest Health Coalition and Think.

NPG Health Collaborative is made up of small rural hospitals, known as critical access hospitals because they provide essential care services in their communities, and their associated rural health clinics. The group has done its own comparison with other heavily rural accountable care organizations, which found that none performed well financially.

Triplett said part of the reason is that critical access hospitals are reimbursed at a higher rate than traditional Medicare pays, a move aimed at helping keep their doors open. Other factors also come into play.

But Triplett said the accountable care organization didn't get into the program to earn savings. Instead, members sought to learn the processes behind value-based programs and managing health.

To that end, the accountable care organization last year launched a commercial program with Blue Cross involving four hospitals and their clinics. Under that arrangement, their reimbursements are the same as other commercial participants.

"That's the important thing," Triplett said. "We're trying to provide better care for our patients and be more focused on wellness versus treating illness."