I am proud to be a member of Whittier Street Health Centers Foundation Board and was delighted when our very able CEO, Frederica Williams, recently asked me to talk to the organization about ACOs at their Grand Rounds. Whittier Street is an exceptional example of a practice that will be sorely tested by the chaos that Jonathan Oberlander describes in his “Perspective” article, “The End of Obamacare”, in the January 5, 2017 issue of the New England Journal of Medicine. There is no certainty about the path organizations should follow over these next four years in the era of “repeal and replace” or to quote Oberlander.
A host of health system stakeholders — hospitals, doctors, insurers, and others — will be anxious about the current uncertainty in the health policy landscape and worried about any changes that substantially reduce insurance coverage and adversely affect their bottom lines. Much of the health care industry supported the ACA as part of a broader coalition that included consumer groups. Whether that coalition can reassemble to effectively resist the ACA’s demise is unclear.
That is the question that faces us all, but is of a very great concern for organizations like WSHC where the care of a majority of its patients has some element of public funding. To prepare you for the discussion I need to give you some information about the recent proposals for Medicaid coverage in Massachusetts, demographic and organizational facts about Whittier Street Health Center (WSHC), as well as some background information about Federica Williams, who is a remarkable healthcare leader.
Shortly before the election in November Massachusetts successfully renegotiated its Medicaid waiver with CMS. The process seemed like a huge step forward because it granted the state over 52 billion dollars over five years to restructure the Medicaid program, Mass Health, as an ACO product. It was a heady moment before the confusion created by the election a few days later. WBUR reported:
In statements, [Governor] Baker said the waiver represented a “major step toward creating a sustainable MassHealth system for the people of the Commonwealth,” and federal Health and Human Services Secretary Sylvia Burwell said the waiver was “another step forward in the American health system’s shift toward value.”
Whittier Street Health Center is a Federally Qualified Health Center. Forty two percent of its nearly 40,000 patients identify as African American, forty two percent as Latino, five percent as white, one percent as Asian, and eight percent as “other” (i.e.,more than one race). Within this diverse population there is substantial poverty. Sixty percent of WSHC patients live below the poverty level, and ninety two percent live below two hundred percent of the poverty level. There is also substantial chronic illness. Seventy percent of Whittier’s patients have one or more chronic conditions including diabetes, hypertension, cancer, HIV, or weight disorder. Twenty seven percent have two or more of those conditions. The life expectancy of an individual living in Roxbury, where most of WSHC patients live, is less than 60 years compared with a life expectancy of over 90 years in the different world of the Back Bay neighborhood of Boston, less than three miles and a few subway stops away.
Frederica Williams is the energetic woman who has led WSHC since 2002. She was born in Sierra Leone and educated in Great Britain before coming to Boston in 1984. Since she assumed the position of President and CEO in 2002, WSHC has grown from about 12,000 patients to an expected 40,000 sometime in 2017. Whittier Street moved to a beautiful new Silver LEED-certified health facility on Tremont Avenue in 2012. In 2015, WSHC inaugurated its innovative Health and Wellness Institute to help address chronic diseases in inner-city Boston and to provide affordable access to a state of the art exercise facility and community gardens for thousands of residents and patients in need. Ms. Williams has led a vigorous attack on the social determinants of disease and has spent the last decade preparing WSHC for the transition to value based reimbursement. Despite the preparation, most of WSHC’s revenue up to now comes through fee for service payments. A minority of the patients who get care at WSHC have coverage through a commercial source or a value based contract.
WSHC has close relationships with several area hospitals: Boston Medical Center, Brigham and Women’s Hospital, Beth Israel Medical Center, and Children’s Hospital as well as Dana Farber Cancer Center. Through its relationship with Boston Medical Center, WSHC now has Epic as its EHR and also has its own data warehouse capabilities. WSHC has assets, and it has huge aspirations to improve the care of its populations with challenging needs. WSHC has the willingness to make the Quadruple Aim a reality for its patients and professionals; what it does not have is much experience as a practice with value based reimbursement. It has not been a part of an ACO, although it has prepared for the future by achieving NCQA level III Medical Home certification, and is also certified as an NCQA PCMH Prime practice by the Commonwealth of Massachusetts, which means that it has successfully integrated primary care with behavioral health. WSHC’s approach to appropriate care has been organized into a discrete set of programs and objectives which it has identified as the Boston Health Equity Project.
Against this rich background of accomplishments one could not imagine how an organization could be better prepared to be an ACO, but Ms. Williams is concerned that just having the desire, the assets, and the competencies does not insure that they will be successful as an ACO. The challenge is to organize the aspirations, assets, and competencies of WSHC into processes that will deliver the Quadruple Aim and the benefits it offers to patients, families and providers.
Long before Atrius Health became a Pioneer ACO, one of our board members, Rob Mechanic, showed me a short article in the August 17, 2011 JAMA written by Singer and Shortell, “Implementing Accountable Care Organizations: Ten Potential Mistakes and How to Learn From Them.” Over the years I have gone back to that list many times, and each time I have been impressed with its wisdom. As I thought about the challenges ahead for WSHC and all of the other organizations that want to work to make the MassHealth ACO opportunity a success, I realized once again the importance of this list for any organization that hopes to be a successful ACO. If you do not have access to JAMA, the list is available as part of another Internet article.
- Overestimation of Ability to Manage Risk.
- Overestimation of Ability to Use Electronic Health Records.
- Overestimation of Ability to Report Performance Measures.
- Overestimation of Ability to Implement Standardized Care Management Protocols.The development of care management protocols requires a high level of involvement from clinicians, as well as data collection and assessment. An ACO may misjudge the level of involvement necessary to develop appropriate care management protocols.
- Failure to Balance the Interests of Hospitals, Primary Care Physicians, and Specialists in Creating Governance and Management Processes to Adjudicate Differences. It is imperative for ACO participants to utilize the structure of the ACO to improve on the quality of care delivered and to work together as a team to achieve collective goals.
- Failure to Sufficiently Engage Patients in Self-care Management and Self-Determination.
- Failure to Make Contractual Relationships with the Most Cost-Effective Specialists. ACOs will need to partner with enough specialists to cover the needs of their population, but at the same time, will need to partner with the most cost-effective specialists.
- Failure to Navigate the New Regulatory and Legal Environment.
- Failure to Integrate Beyond the Structural Level. While coordinated care is an important tenet of the ACO on a contractual basis, it may be harder than anticipated to implement it on the ground level.
- Failure to Recognize the Interdependencies and Therefore the Potential Cumulative “Race to the Bottom” of the Above Mistakes. An ACO must realize that all of the potential pitfalls are interdependent, and must be avoided holistically to succeed.
I have attended dozens of meetings about and with ACOs. I have spoken to many audiences about the experience of leading an ACO, and what I learned from the experience. I have worried that most people consider the ACO to be a method of finance and not a philosophy of collaborative care. Through my worries I have come to believe more than ever before that the core to success for ACOs is the ability within the organization for clinicians to adopt team based efforts to deliver care to the individuals of a population, and their ability to coordinate their own activities with the work of their colleagues in specialty practices and in the hospital to eliminate waste.
“Management by process” across the internal silos and the competing interests of external institutional partners is only possible if all parties to the process realize that the best way to protect their self interests is to make the concerns of patients and the community their own primary concern. At this time the interlocking concerns of patients and the community are access, quality and cost. Obamacare has been criticized because costs appear to remain high although there have been improvements both in cost and quality that health policy experts can demonstrate. A growing number of patients have found it to be an improvement to what they have had, if not exactly what they wish it could be. Whatever the repeal and replace process turns out to be, it will be a failure that will demand accountability of the party in power if it does not expand access, reduce cost and improve quality.
Massachusetts and the committed clinicians and healthcare leaders who care about the dream of…
Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness
…will be challenged over the next four years, but I remain hopeful that just as it led the way to better care before the ACA, Massachusetts and its healthcare professionals and organizations will continue to lead the way to better care through the swamps of repeal and replace. I hope that across the state and around the country there will be hundreds of organizations like WSHC where leaders and clinicians are willing to change together as they learn how to deliver the dream.
