Cybersecurity: Nightmare scenarios and guiding principles

From legacy infrastructure to potential medical device hacks, some of the industry’s leading voices opened up about how the industry can begin to combat the inevitable breach.

By now, the healthcare sector is fully aware of the looming target placed on its back by hackers. The issue is that legacy infrastructure, staffing shortages and insider threats can make it tough to tackle these issues.

The biggest threats lie within the legacy infrastructure of healthcare itself. This includes medical devices operating on outdated platforms, along with IoT devices. We have not have seen it happen frequently but, if those devices are hacked cybercriminals can actually put patient lives at risk.

But security risks go beyond a breach. In healthcare, when a hacker gets in it often interrupts patient care, throws clinicians back to pencil and paper and downtime can last for weeks.

Consider the WannaCry attack that crippled the U.K. National Health Service last year.

Hackers are hitting EHR vendors, as well, which impacts providers operating on the impacted platforms. Allscripts was hit earlier this year, and some of its providers were unable to access patient records for up to a week.

“Breaches are always a concern, but lack of access to data and extended downtime with no access to records has huge impacts for revenue, patient care and community trust,” said Max Stroud, lead consultant with Galen Healthcare Solutions.

For some, the crux of security issues lies with the users. Often seen as the biggest threat, “user threats have the potential to cause significant losses and evade detection.”

Indeed, insider threats have been the biggest vulnerability to healthcare security for more than a year. Verizon’s April breach report found insider threats and human error were the biggest risks to security. In fact, healthcare is the only industry where insider threats outnumber outside threat actors.

Incremental steps and human-centric design

What can be done given the attack surface and seeming inevitability of a breach?

“A viewpoint has emerged in the last few years that organizations should just assume they are going to be compromised, so they should focus their efforts on detection and response for when an attack inevitably happens,” said a spokesperson from health IT firm Cognosante.

Detection and response, however, only comprise half the equation: “It’s a huge mistake to back off on preventive controls like strong access control, web application security, adaptive firewalls and user awareness training.”

Several experts said security needs to be designed with the user in mind. According to Stroud, she’s seen doctors share their passwords with nurses in order to complete charts, as it’s seen as “a care efficiency and not a risk.”

Even worse, Stroud said, “I’ve also seen EHRs delivered with standard admin logins. It’s not pretty out there.”

“Human-centered design should account for human-centered tendencies,” said Geeta Nayyar, MD, Femwell Group Health’s chief healthcare and innovation officer. “Understanding how we can help our folks develop an internal motivation to actively embrace the role of our first line of defense.”

With that in mind, organizations need to make it nearly impossible to do the wrong thing, Harlow added. “Very important to reduce exposure, reduce public face, limit internal access on role-based need-to-know basis.”

Organizations should also conduct pen testing and bug bounty programs on the regular to make sure they’re not susceptible to attacks.

“You can try to predict the future, or you can just continually review and improve your systems, processes, personnel, training, etc. including doing new risk assessments as changes are made,” said Harlow.

“We plan for what we can plan for – but there are many unknowns in this business,” said Nayyar. “Keep solid post-event contingency and crisis plans current.”

Ascension forges first-ever global supply chain company to reduce costs

Ascension is partnering with a large Australia-based international hospital company to form what appears to be the first-ever global supply chain firm.

A major goal of the joint venture between Ascension and Sydney-based Ramsay Health Care, announced Tuesday, is to reduce costs at Ascension’s 151 U.S. hospitals and hundreds of other not-for-profit facilities to the levels in lower-cost countries.

“We believe our providers, and any providers, want products at high quality and lower cost,” Ascension CEO Anthony Tersigni said in an interview. “This gives us visibility into product offerings around the world, and patients will benefit from this greater awareness.”

he joint venture is part of Ascension’s new strategic direction, announced in March, that includes downsizing hospital operations and expanding ancillary businesses such as group purchasing.

Until now, there have been no meaningful efforts to rationalize the healthcare supply chain internationally, even though that’s been done in other industries. Much higher prices for drugs and other products in the U.S. are a major contributor to much higher healthcare spending here compared with other advanced countries.

Rob Austin, director of healthcare consulting at Navigant, said the deal could help reduce U.S. healthcare costs if it helps Ascension learn how much other countries pay for medical products, and it uses that knowledge to negotiate lower prices for U.S. providers.

“Especially with pharmaceutical drugs, if they could get the pricing, that would really make an impact on bending the cost curve,” he said.

But Austin cautioned that it won’t be easy for the new buying group to navigate the differing regulations in each country, particularly when it comes to drugs and medical devices.

The deal, finalized on Tuesday, will be owned equally by Ascension and Ramsay, a for-profit company founded in 1964. Ramsay owns 230 hospitals and outpatient surgery centers in six countries—Australia, France, Indonesia, Italy, Malaysia and the United Kingdom. It’s the largest private hospital operator in Australia and France. It reported revenue of about $6.5 billion (in U.S. dollars) last year, with a net profit of $451.5 million.

Ascension reported $552.7 million in operating income on net operating revenue of $22.6 billion in 2017, down 27% from $753.2 million in operating income on revenue of $21.9 billion in 2016.

In a written release, Ramsay CEO Craig McNally said the new global buying group will seek products internationally that deliver a high level of service and clinical outcomes. This partnership “will allow us to share learnings, best practices and industry knowledge to seek improved quality and outcomes whilst also reducing costs,” he said.

Ramsay’s share price dropped 4% Monday on news that McNally sold 75,000 shares of his company last week for about $4.8 million. The company said McNally sold his shares primarily to meet personal income tax obligations, The Motley Foolreported.

Through the joint venture, Ascension initially will seek out global sources mainly for medical-surgical products such as gowns, sutures and mattresses. It may also source some pharmaceutical products, most likely generic drugs. Later, the buying group may move into medical devices, implants and a broader range of drugs—all of which would face much tougher regulatory hurdles.

Tersigni said he wants the joint venture to extend Ascension’s reach domestically and internationally, strengthen Catholic healthcare, and help his organization gain insight into clinical research around the world.

“Vendors will benefit from having a single point of negotiation to an international platform like ours and streamline discussions between them and health systems,” he said.

Ascension will benefit from Ramsay’s experience in buying products to meet the needs of providers and patients in different countries. For instance, in some Asian countries, people are smaller in stature and require smaller scrubs. In addition, each type of hospital staffer may wear a different color scrub. In the U.K., hospital basins and bedpans are made of disposable cardboard rather than plastic.

Ramsay could gain insights from the operating model of Ascension’s group buying division, called the Resource Group. It focuses on streamlining the purchasing process to reduce vendor costs and thus enable them to offer lower prices without sacrificing profit.

The Resource Group manages a portfolio of $7.7 billion in annual spending for supplies, purchased services, pharmacy, construction materials, capital and IT, and it claims to save participants $1 billion annually.

It plans to channel about $143 million in spending through the new buying group in the first year.

Hospitals around the world buy the same types of products but pay sharply different prices in different countries. “If the new buying group shares any of that comparative pricing, that will be really eye-opening,” Navigant’s Austin said. “Imagine price transparency around the globe. That will call suppliers on the carpet for pricing much more aggressively in the U.S. than in other places.”

Atrium Health to merge with Navicent

Atrium Health, previously Carolinas HealthCare System, and Navicent Health signed a letter of intent to merge, the organizations announced Thursday.

The merger of not-for-profits would give Atrium Health a regional presence in Georgia, opportunity to expand to other areas and bolster its service lines. Macon, Ga.-based Navicent, which would become part of Atrium, would gain access to capital and benefit from spreading costs over a wider patient base.

The announcement came a day after Carolinas HealthCare changed its name to Atrium, in part because it wanted a name that didn’t limit it to a certain geography.

“As not-for-profits continue to come together to build scale to drive affordability, care quality and cost savings, we are doubling down on that idea, and shouldn’t be limited to inside the state lines,” said Gene Woods, president and CEO of Charlotte, N.C.-based Atrium. “Navicent has a regional hub in Georgia and we can help broaden the community they serve, and possibly create a model for further expansion.”

Both organizations, which operate on Cerner’s electronic health record, are committed to caring for vulnerable communities and improving access, said Navicent President and CEO Dr. Ninfa Saunders. Saunders also co-founded Stratus, a collaboration of physicians and hospitals that aims to fill information gaps to better care for rural communities.

“This gives organizations around us an opportunity to join us,” she said. “Hopefully there is a catalytic function to this strategic combination.”

Whether it’s a certain service line, a favorable payer mix or additional access points, health systems have targeted particular regions to grow, picking up where national players have struggled to manage costs and realize a return.

Navicent is building Beverly Knight Olson Children’s Hospital in Macon, Ga., which complements Atrium’s Levine Children’s Hospital in Charlotte, Woods said. There are also opportunities to expand oncology lines, post-acute care, telemedicine and behavioral health services.

“Sharing our infrastructure and analytics will give us the ability to better manage populations and identify best practices,” Woods said.

Atrium, the largest hospital system in North Carolina, is also pursuing a mergerwith UNC Health Care, based in Chapel Hill, N.C.

2018 Outlook on Politics and Policy: Insurers will come out ahead

Despite a year of policy delays, glitches and uncertainty, insurers may be the ones to come out ahead of other segments of the industry in 2018. Uncertainty and policy confusion will no doubt continue this year since House and Senate Republicans are already on different pages when it comes to healthcare reform.

Now that the GOP’s $1.5 trillion tax overhaul is done, House Speaker Paul Ryan (R-Wis.) is setting his sights on entitlement reform as a way to rein in costs. This could mean trimming welfare, Social Security and Medicaid, but he has signaled Medicare provider cuts are also on the table.

In the Senate, Majority Leader Mitch McConnell (R-Ky.) and members of the GOP leadership consortium—Sens. John Thune of South Dakota and John Cornyn of Texas—say they want to go the bipartisan route and look at individual market stabilization measures proposed by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.)

But then GOP Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina want to revive their proposal to block-grant federal money for Medicaid and the Affordable Care Act exchanges. This idea was killed last summer during the Senate’s failed attempts to repeal the ACA.

Medicaid, which Republicans wanted to convert to a capped per-person payment structure, could get new attention.

“It makes a lot of sense,” Thune said.

Meanwhile, President Donald Trump could use executive branch power to continue striking major blows to the ACA’s individual market risk pool.

So 2018 is shaping up to be another sink-or-swim year in healthcare: Adapt to the new rules—or lack of rules—or try to write them yourself.

Who’s going to do well in this environment? Whether you look at Centene Corp. in the individual market or the likes of UnitedHealthcare, CVS Health and Aetna competing for greater market share, including the Medicare Advantage space, the payer community is poised to fare well in the new Wild West of policy. This despite the fact that last year’s tax overhaul effectively killed the individual mandate by eliminating the penalty for people who fail to obtain coverage.

For other stakeholders—hospitals and providers who have watched helplessly as key programs lapsed without Congress mobilizing to fund them, or the Trump administration pivoting on value-based payment initiatives—the future isn’t necessarily so bright.

As we tumble into 2018, Congress still has a long must-pass, way-beyond-deadline healthcare agenda. But from what’s known, here’s an early look at Modern Healthcare’s projected winners and losers in 2018.

UNFINISHED BUSINESSLawmakers return to the nation’s capital with a lot of work left over from 2017.

• Children’s Health Insurance Program: The short-term budget patch approved in late December added $2.9 billion to CHIP, funding it through March.

• Medicare extenders: The enhanced low-volume adjustment and the Medicare dependent hospital program were lost in the shuffle in the weeks leading up to the short-term spending deal.

• Affordable Care Act taxes: There have been some bipartisan conversations about delaying the Cadillac tax, the employer mandate, the health insurance tax and the medical-device tax, but both sides are still talking about compromises to pay for them.

• Individual market stabilization: The government is paying out more in premium tax credits now that cost-sharing reduction payments are gone. There’s a rift within the GOP on how to handle CSRs.

• Opioid epidemic: Leading senators on both sides want to give President Trump’s public health emergency declaration heft with funding, but so far they haven’t agreed to a number.

• Drug pricing: Health committees in both the House and Senate have started to look at drug pricing and HHS Secretary-designate Alex Azar addressed the issue at length in his first Senate confirmation hearing.

Providers and vendors team up for user-friendly EHRs

Before an Allscripts electronic health record appears on screen, it first appears on a storyboard—sometimes even a paper one. That’s where Allscripts developers can test new ideas on providers, figuring out what should go where.

“The design on paper is still at the basic level where we can change on a dime,” said Ross Teague, director of user experience for Allscripts Healthcare Solutions. Users usually feel more comfortable offering feedback on a design when it looks unfinished.

 

THE TAKEAWAYElectronic health records are notoriously clunky. Vendors, with the help of their provider clients, are out to change that.
Such interaction is crucial, given that clinicians spend about half the workday working with EHRs. And many of those hours are during patient encounters. A study in the Annals of Internal Medicine found that ambulatory physicians spent more than a third of their time with patients on EHR and desk work tasks. That makes many providers unhappy, and not just because it affects their face-to-face time with patients.

“The challenge of established EHRs is that so much functionality gets piled onto these complex systems,” said Dr. Titus Schleyer, a research scientist with the Regenstrief Institute.

But as providers complain, vendors respond. Allscripts, Athenahealth, Cerner Corp. and Epic Systems Corp. are among those constantly tweaking their software after getting feedback from the source of those complaints. They’re consulting with and observing users inside and outside of their natural work environments to build EHRs for efficient—and pleasant—workflows, layouts and functionality.

Most, if not all, major EHR vendors rely on a combination of formal user testing, informal feedback, and what might be called ethnographic research. The result isn’t just happier clinicians but safer healthcare delivery.

“Many of the same issues that can lead to clinician frustration with EHRs can also lead to safety problems,” said Ben Moscovitch, manager of health information technology for the Pew Charitable Trusts. For instance, if a clinician accidentally orders a medication for the wrong patient, correcting the error can be cumbersome, requiring multiple steps, he said. The EHR can be tweaked to address that.

 

A partnership

With healthcare perpetually inching toward value-based care, EHRs are more important than ever in helping patient care. Vendors are working with providers to improve their offerings, going beyond meeting the bare minimum federal requirements for their software.

Athenahealth, Allscripts and others have formal programs to gain insight from their provider users both while software is in development and after. “That relationship has really improved the way the system works for us and, I would presume, because of the way Athena works, for all of its customers,” said Steven Kelley, CEO of Ellenville (N.Y.) Regional Hospital, which, as an Athenahealth development partner, tries out prototypes with new features.

That kind of relationship also helps vendors, which learn from their users early on what kinds of features they’re interested in and how those features should work.

“In a good user-centered design process, you’re involving your users early and often,” Allscripts’ Teague said. His company does formative testing with its users during which they engage in the aforementioned and try new versions of the software. “This is the No. 1 method by which we collect patient-safety issues before they ever become patient-safety issues,” he said.

Allscripts also gets new product ideas by observing clinicians in care settings. Sometimes, for instance, to get an objective sense of how well its software works, Allscripts will measure how many users can complete a certain task without any training.

Observational research is particularly helpful given how providers talk about what they want from their EHRs. “Sometimes, what people say only reflects part of what their goal is,” said Janet Campbell, Epic’s vice president of patient engagement. “If you give a doctor a list of 10 activities in the record and you say, ‘How many of these would you like to see on the screen?’ they’ll say, ‘All,’ ” she said. “It’s not until you watch how they interact and move back and forth that you realize that they only need three of those things.”

When Athenahealth is testing a feature in the alpha or beta stage, the company uses behavioral analytics to glean how users are interacting with it. “One of the benefits of being cloud-based is that all the data across our network is very accessible, and we can see the actions people are taking,” said Scott Mackie, Athenahealth’s executive director of strategy design and user experience.

For instance, when the company was developing a timeline feature, users complained about how many clicks it took to see everything that had happened to a patient over time. Athenahealth developers watched how the timeline affected workflow so developers could lay it out to highlight the most useful and appropriate events and data. Giving clinicians the information they need when they need it could help them better care for patients, since it would reduce their workload and help identify important elements quickly. “Physicians want the right information at the right time at the right point of care, and that helps them provide better care,” said Rich Berner, Allscripts’ senior vice president of health systems and population health solutions management.

Presenting information, not data

Part of the reason vendors must revise and tweak EHRs is because of their complexity, Schleyer said. It’s hard to design a program that’s usable “right out of the box.”

To deliver a more consistent patient and user experience across its facilities, SSM Health consolidated its three versions of Epic into one. “We called the project that we worked on ‘simple elegance,’ ” said Philip Loftus, SSM’s chief information officer. “If it took you five screens to do something, we tried to bring that down to two or three screens.”

The improvements came from Epic’s collaboration with SSM and from SSM’s own developers, who get regular feedback from physicians and from consumers surveyed after the health system updates software.

One request was to display all information relevant to patients’ care on one screen.

Physicians want all of that information at the top level, Mackie said. “They want less digging,” he said. A solution could be building artificial intelligence into the EHR so it learns the most important information, he said. Another solution might be voice, especially as it becomes more common in consumer life.

Increased population health efforts also have vendors considering how new kinds of data should be presented.

“People aren’t asking for data—they’re asking for information,” Teague said. “That means fitting it into their workflow and making sure it’s presented in a way where they’re not spending a lot of cognitive effort determining what it means.”

Top heart hospitals zero in on continuum of care

Before cardiac surgery patients are discharged from St. Luke’s Boise (Idaho) Medical Center, they are referred to the hospital’s cardiac rehabilitation program.

The 12-week program offers routine monitoring by clinicians for patients who recently underwent open-heart surgery, a valve replacement or any other type of cardiac procedure.

The rehab center is staffed with a multidisciplinary team of healthcare professionals including physicians, nurses, respiratory therapists, dietitians and social workers. The program provides patients additional education about their disease, help with personal issues that might prevent them from following the treatment plan, and exercise and nutrition courses that can help speed their recovery.

About 95% of cardiac surgery patients enroll in the program, and it has contributed to lower readmissions since it launched in 2009. About 14.7% of heart attack patients are readmitted to the hospital after 30 days, below the national average of 16.8%.

“We try to standardize follow-up within our practice,” said Dr. Stefanie Fry, chair of the department of cardiovascular services at St. Luke’s Boise.

The sharp focus on ways to address every aspect of the care continuum is a hallmark strategy of St. Luke’s Boise and other hospitals recognized this year in the Watson Health 50 Top Cardiovascular Hospitals (formerly known as the Truven Health 50 Top Cardiovascular Hospitals) study. Hospitals considered to be leaders in cardiac care standardize and invest in approaches that not only improve the health of their patients during their inpatient stay but long after discharge as well.

Focus on the continuum of care is in line with the move to value-based payment, said Jean Chenoweth, senior vice president of the Center for Performance Improvement at IBM Watson Health.

“Value is starting to increase over time,” Chenoweth said. “When hospitals are focused on the continuum of care and they don’t let it go, they maintain their focus on that quality of care and the industry changes as a whole.”

The 19th annual study reviewed 1,016 hospitals and recognized 50 that provide exemplary care in one of the industry’s largest specialties. Heart disease is the leading cause of death for men and women in the U.S., accounting for 1 in 4 deaths every year. And each year about 735,000 Americans have a heart attack, according to the Centers for Disease Control and Prevention.

The 50 hospitals on Watson Health’s list scored higher than their peers on clinical outcomes for heart attack and heart failure treatments, as well as coronary bypass and angioplasty surgeries. The hospitals performed better on mortality and complications, as well as 30-day mortality and readmissions. On average, their procedures cost less and patients had shorter hospitals stays.

Similar to previous years, Watson Health divided the top hospitals into three categories—15 teaching hospitals with a cardiovascular residency program, 20 teaching hospitals without such residency programs and 15 community hospitals.

To get its results, Watson Health uses the most recent CMS data from the Medicare Provider Analysis and Review file, CMS Hospital Compare and Medicare cost reports. Watson Health also added two new measures this year to its analysis: 30-day episode payment for heart attack and heart failure patients. The additional measures reflect the movement toward population health management as hospitals are expected to manage the quality of care of patients after discharge, said Julie Shook, 100 Top program director of value-based care at Watson Health.

Chenoweth said it’s increasingly difficult for 50 Top hospitals to beat their peers because cardiovascular care overall is improving. Indeed, the 50 Top hospitals performed less than 1% better than peers on 30-day mortality and readmission rates for heart failure, heart attack and coronary artery bypass surgery patients.

“The fact is quality is improving in cardiovascular care over time,” Chenoweth said. “The hospitals are benefiting from newer technology and treatments.”

The vast majority of the 50 hospitals being recognized for their cardiac care were veterans on the list, but there were also eight newcomers, including Wake Forest Baptist Medical Center, a teaching hospital in Winston-Salem, N.C. The hospital has recently focused on ways to prevent costly readmissions and streamline post-discharge care among its heart patients, said Dr. David Zhao, chief of cardiovascular medicine at Wake Forest.

In 2014, the hospital began to incorporate pharmacy technicians into the discharge protocol. The patients receive a 30-day supply of their prescribed medication before they leave the hospital, up from just a seven-day supply. The longer time period ensures patients stick to their medication regimen and have time to sort out a prescription refill, Zhao said.

Additionally, 48 hours after patients are discharged, a nurse calls to check in on their health status and to make sure they are following the care plan. A mandatory follow-up appointment also occurs at the hospital seven days after discharge.

The hospital has seen its readmissions rate fall since the initiative was launched. “We can understand if there are issues medication-wise, or with their living circumstances like transportation—those are things we can catch earlier and intervene so they won’t be readmitted,” Zhao said.

But ensuring appropriate follow-up with patients after discharge isn’t without challenges. Wake Forest cares for a large rural and Medicaid population, so the hospital needs to coordinate care for complex patients, Zhao said.

“Enough manpower has always been a challenge,” he said. “Who is going to make phone calls to patients and make sure they can care for themselves?”

Anthem CEO Joseph Swedish to retire

Joseph Swedish is retiring from his post as CEO of Anthem, the second-largest health insurer in the nation.  Swedish will be succeeded by Gail Boudreaux, the former CEO of UnitedHealth Group’s insurance arm.   The leadership shift has been in the works for a year, Swedish said, and the company plans to make the announcement Monday. It is unclear when the official transition will occur.

Swedish’s career in healthcare spans more than four decades. He has worked for Indianapolis-based Anthem, a licensee of the Blue Cross Blue Shield Association, since 2013 when he replaced Angela Braly as president and CEO. He became chairman in 2015.  Before Anthem, Swedish was CEO of Livonia, Mich.-based Catholic hospital system Trinity Health, an office he took in 2004.

During his tenure, Swedish saw Anthem’s annual revenue balloon from $71 billion in 2013 to $84.9 billion in 2016. Anthem serves about 40 million members in 14 states.

He led the insurer in its effort to acquire rival insurer Cigna Corp. in a deal valued at $54.2 billion. The contentious tie-up was ultimately abandoned after being challenged by the U.S. Department of Justicce for threatening to harm competition.

Anthem last month announced the formation of its own pharmacy benefit manager, IngenioRx, in the wake up its fallout with long-term PBM partner Express Scripts.

Swedish made $16.5 million in total compensation in 2016, according to documents filed with the SEC.

Delivery system reform hampers ACO progress on risk-based contracts

Accountable-care organizations are participating more and more in risk-based contracts, but that progress has been stalled by sluggish care-delivery changes, a new survey suggests.

Roughly 50% of ACOs are involved in at least one downside risk contract, such as shared savings and capitation contracts, according to a Leavitt Partners and National Association of ACOs report recently published in Health Affairs. About 47% of ACOs plan to participate in shared-savings risk-based contracts in the next year or so.

However, ACOs are focusing mostly on “low-hanging fruit” strategies to save money and improve quality of care, which mitigates how well the organizations are able to perform in riskier contracts, the report said.

“Even though ACO providers say they are preparing for and assuming risk, the care delivery system is not advancing as quickly as the payment system reforms,” said Kate de Lisle, an author of the study and a senior analyst at Leavitt Partners. “In order for these payment models to be successful, providers need to change the way they deliver care.”

Most ACOs still largely focus on “first wave” care delivery changes like readmissions, emergency department use and chronic care management, the report said. ACOs haven’t yet tapped into other reforms that will also help them prepare for downside risk like behavioral health integration and medication optimization and management.

Behavioral health and medication management contribute to high healthcare costs, and ACOs farther along in the model have started to address those aspects of care, de Lisle said.

Approximately one-quarter of all ACOs, or 240, responded to the survey. The respondents ranged from urban to rural ACOs as well as physician-led, hospital-led and integrated ACOs.

The survey found that hospital-led ACOs are more likely to have a shared-savings contract with downside risk than a physician-led contract. About 48% of hospital-led ACOs said they currently had a risk-based contract, compared to 28% of physician-led ACOs. Physician-led ACOs might have stalled because they have fewer resources than large systems to secure the capital needed to participate in risk-based contracts, de Lisle said.

“Though the physician-led ACOs have fewer active shared-loss contracts, they are still planning to participate, they are just behind a little bit,” she said.

Previous research has even shown that physician-led ACOs are more likely to be successful in the model because they have a deep understanding of their patient populations, she added.

But delivery system reform hasn’t kept pace with payment reform. The CMS and other payers haven’t offered providers much of a road map for adopting changes to care management. As a result, physicians are trying many different tactics all at once to see what does and doesn’t work, de Lisle said.

That hasn’t stopped providers with several years of ACO experience from generating savings. A recent study from HHS’ Office of Inspector General found the 423 ACOs participating in the CMS’ Medicare shared-savings program reduced spending by about $1 billion in three years.

De Lisle encouraged providers to keep working at their ACOs and to not give up. “The longer you are working with these goals and align your system, you begin to figure it out,” she said.

The survey also revealed that ACOs spend an average of $1.1 million on care management, and nearly all ACOs — 95% — use care coordinators to help manage their patient population.

“Care coordinators are these Swiss army knife team members that can be used in a number of ways,” de Lisle said.

The ACO model is by the far the most popular in the push to value-based care. As of the first quarter of 2017, 923 private and public ACOs were in operation, covering more than 32 million patients, according to a June 2017 post in Health Affairs by Leavitt Partners.

“Because the ACO model has been the primary vehicle in value-based care, I think studying the ACO movement will allow us to better understand where we are on the broader spectrum,” de Lisle said.

By Modern Healthcare.