I like trains. Perhaps it is because my maternal grandfather worked all of his life for the Seaboard Railroad. Some of my earliest memories are of going down to the train station with him when we would visit the little town in North Carolina where I have had family for over 200 hundred years. He never owned a car so it meant that we would walk. The big event of the trip was to climb the big wooden stairs to the loading dock where there was a huge scale with a long arm where various counterweights dangled. I would climb up on the scale and “Papa Childs” would exchange the circular heavy weights on the arm until just the right balance was found. He would then announce with great pomp and circumstance just how much weight I had gained since my last visit.
I always thought that my grandfather was a very important man. He could ride the train anywhere he wanted to go for free and take anyone he wanted along for free also. He even rode the train to see me in Oklahoma. With that sort of perk who needed a car?
Unfortunately, my grandfather’s constant pipe smoking and his genes felled him with a huge myocardial infarction at the age of 64. He did at least 10,000 steps each day walking to the station in the morning, home for lunch, and then back to the station and home again in the evening. My guess is that the pipe, his love of steak and eggs, and his genes were too much of a counter balance.
The “medical train” my grandfather rode in 1953 was not very fancy compared to the ride we offer cardiac patients now. I got on the train in the late sixties and my first thought was how much further Papa Childs might have been able to ride if he had been offered the same options that I was offering to my patients.
My uncle and my mother both got genes from Papa Childs. Uncle Jim made it to 76 with two CABGs and an early version implanted defibrillator. Mother made it to 93 with the aid of forty years of antihypertensives, a quarter century of cholesterol management, an LAD angioplasty, and a pacemaker. The train rolls on. I have been on anti-hypertensive meds since my late teens, always exercised, never smoked, and have taken statins for over twenty years. I hope to ride the train until I reach three digits.
Until recently most of us have been on a better train than the one our ancestors rode. Collectively we’ve invested in basic medical research, new life saving technologies, and more effect medical treatments. The ACA was an attempt to extend those benefits to everyone.
A train can’t go where there is no track, and progress requires a goal before the tracks to the goal can be laid. To stretch a metaphor, the ACO movement and the ACA that was designed to support it are like tracks that have been laid by the evolving experience of forward thinking providers of care like Kaiser and organizations like the Institute for Healthcare Improvement (IHI) launched by Don Berwick and others in 1991. Many of us have been traveling those tracks since the launch of the Triple Aim in 2007-2008.
To really torture the metaphor, many healthcare organizations and practices that were attracted to the Triple Aim have had trouble “staying on track.” Once a train or an organization gets off the track it is very hard to get back on track. The only example I know of a train getting off the tracks and then back on again is from a little Golden Book about “Tootle,” a nonconformist little train that hopped the tracks to chase butterflies. As the review in Amazon now says:
In this classic Little Golden Book from 1945, Tootle is a young locomotive who loves to chase butterflies through the meadow. But he must learn to stay on the tracks no matter what—if he ever hopes to achieve his dream of being a Flyer between New York and Chicago!
I would like to think that my former colleagues at Atrius Health are more like the better known “Little Engine That Could” because they have stayed on track and have always been motivated by the goal of getting over a mountain of resistance in the market on their way to the Triple Aim.
The Little Engine That Could came to the rescue when stronger engines refused to help after the engine of the train that was carrying toys and goodies to the good little children on the other side of the mountain broke down. The little engine strained and struggled, but it kept saying, “I think I can, I think I can” until it did get over the mountain. My grandson would probably reference “Thomas The Train,” an introspective little engine whose every adventure teaches another lesson in empathy and morality.
The Atrius train has always set the Triple Aim as its destination.. At the time Atrius signed the AQC it had not gotten off track completely, but its “risk patients” had fallen from almost 100% of total patients to less than 40% as the practice struggled through the crash of managed care. HMO had become a four letter word.
More than a decade ago Atrius set a goal of moving toward more and more risk contracts because those contracts rewarded its ability to lower the cost of care while generating margins that allowed it to improve quality, safety, and service. Atrius took the big step of being the first organization to sign the Blue Cross Alternative Quality contract (AQC). After the ACA was passed it was eager to be part of the Pioneer ACO project offered by CMMI.
The cards were stacked against Atrius in the Pioneer ACO since its costs for Medicare were already the lowest in the market which made its budget lower than local competitors. The phrase “no good deed goes unpunished” was uttered frequently, as was “Medicare is the “world’s largest PPO,” as skeptics implied that there was no way to “keep patients in network.”
The culture of quality at Atrius gave it one of the top quality scores in the Pioneer ACO experiment. In 2016, the last “Pioneer year,” Atrius had the highest quality of all of the Pioneers and saved CMS over ten million dollars. After “graduating” to the Next Generation Medicare ACO contract their success has continued. In a news release in early 2018 Atrius proudly announced:
…its Next Generation Accountable Care Organization (ACO) has achieved strong clinical quality and patient experience scores from the Centers for Medicare & Medicaid Services (CMS) and saved CMS $19.9 million…These results demonstrate the organization’s continued success in achieving the Triple Aim of improving health outcomes and patient experience as well as reducing the total cost of care.
What Atrius learned with the Alternative Quality Contract and the Pioneer ACO led to immediate success with the Next Generation Medicare ACO and prepared it to be a leader when Massachusetts began the process of putting all of its Medicaid recipients into ACOs. The Health Policy Commission (HPC) in Massachusetts was charged with certifying ACOs to accept Medicaid patients. Atrius Health’s demonstrated success in commercial and Medicare ACOs led to being quickly certified by the HPC as a Medicaid ACO. Atrius Health’s CEO, Steven Strongwater, summed it up nicely in a press release.
“For decades, Atrius Health has delivered superlative care with accountability for cost, quality and patient experience to keep the communities we serve healthier,” said Dr. Steven Strongwater, President and CEO of Atrius Health. “We are delighted to have been selected for this first-of-its kind program, and look forward to our continued collaboration with the Health Policy Commission in an effort to reduce the total cost of care in Massachusetts and better serve patients across the Commonwealth.
My reference to Medicare being the world’s largest PPO was an introduction to the toughest hill the little Atrius engine needed to climb to convert the largest number of fee for service patients to risk contracts. As patients fled the closed networks of the managed care era, many employers offered their employees “choice.” In the preferred provider organization (PPO) contracts that became more and more prevalent, patients were no longer required to identify a “primary care physician” and could move about seeking care. Without “attribution” of patient to PCP it was hard for most healthcare professionals to understand how they could accept risk on patients who had no contractual restraint on their utilization of medical resources.
Over the last twenty years Atrius has cared for tens of thousands of PPO patients in exactly the same way they treated their risk contract patients. Experience has taught Atrius that a high degree of satisfaction with the care received and the natural affiliation of long term relationships were much better than the chains of a contract that forbade choice. Most patients will choose to follow the lead of a clinician they trust. It is one thing to think that your patients will follow your advice, and another to sign a contract that could result in millions of dollars of loss if you are wrong. This last week Atrius Health delivered on something that had been under consideration for a long time. They agreed to a relationship that moved PPO patients from Fee for Service to risk contracts. The news broke in the Boston Globe and on local public radio last Friday, but the most complete report was the press release from Atrius.
Atrius Health and Blue Cross Blue Shield of Massachusetts (“Blue Cross”) today announced a new seven-year agreement in which the two independent organizations will align around an advanced alternative payment model to co-create a new kind of health care experience that’s simpler, easier to navigate, higher quality, and more affordable.
The agreement builds on the innovative work the two organizations have done together, beginning a decade ago with Blue Cross’s pioneering Alternative Quality Contract (AQC),… which reshaped health care in the Commonwealth and nationally, Blue Cross and Atrius Health are now collaborating again to create a seamless health care experience as well as new products and services…
The agreement will also take alternative payment innovations to the next level…This is the first Blue Cross provider contract and first Atrius Health payer contract to have full risk (cost and quality accountability) for PPO members. In addition to supporting better alignment across the two organizations, this agreement will allow Atrius Health to better invest in care delivery models to improve patient experience, slow health care cost growth and provide the right resources to help people stay healthy and out of the hospital or emergency department.
I am so proud of the people at Atrius and at Massachusetts Blue Cross whose hard work has made this agreement and partnership possible. Atrius will continue to have hundreds of thousands of patients from other insurers like Tufts and Harvard Pilgrim Healthcare, and one could argue that in effect Blue Cross may be subsidizing their care. I know that I could make that same argument for their Alternative Quality Contract of a decade ago. Atrius and the Massachusetts Blues have been partners for innovation now for twenty years, and the original Harvard Community Health Plan was initially offered in 1969 through Blue Cross before the practice became self insured.
The AQC took off with other Massachusetts provider organizations after Atrius took the first leap. Perhaps it will happen again and we will see that for more patients the total cost of care will go down as the quality and satisfaction rises. I would like to think that Atrius and Blue Cross are moving down the track together toward the Triple Aim with others not far behind. I know they must be repeating again and again, “We think we can! We think we can!
