Perspectives

It was the coffee that did it to me. “You can’t have real coffee,” the room service dietary person said, “decaf. You’re on a cardiac diet.” She had already refused my request for orange juice, for waffles, for a short stack of pancakes—“You’re on a diabetic diet.” But, I remonstrated, my sugars are normal and at home I eat a regular diet. “Not on your life,” she replied. You have to get your doctor or your nurse to change the diet order. “You’re on a cardiac-diabetic diet.” But I’ve talked with my cardiologist and he says a couple of cups of coffee a day are OK. “Nope, not from us, it isn’t.”

My last meal was the evening before. Nothing to speak of for breakfast and then no lunch, of course, since my cardiac angiogram had been scheduled for 2:30 pm and then started an hour late. It was now dinner time and I was famished. I especially wanted that cup of coffee. My doctor had gone back to his office and in a hospital staffed with many many nursing people, I didn’t know who my nurse was. Worse yet, I had sent my eyeglasses home with my wife along with my clothes. I couldn’t see the button to summon help (although it wouldn’t have been much help, I also couldn’t see the TV up on the wall). Besides, flat on my back, after strict instructions to lie flat for 12 hours after the angiogram femoral stick, I couldn’t even find the nurse call button.

I tried pulling rank. “I’m a doctor myself, you know.” No luck. The dietary limb of this new hospital stood firm.

Eventually, many hours later (maybe ¾ of an hour), maybe days later, my real nurse came in. She introduced herself, “Susan,” and told me she was to be “my main man” and that “she had the keys to the kingdom.” Specifically, she could change the dietary order. Breakfast appeared at 8 pm. Yum! Real coffee, not decaf.

I was in the hospital to figure out why my angina pectoris had returned.

It arrived about 20 years ago. A diminution in the distance I could run without stopping because of a new sensation, a heavy rock in my chest. No big problem; I could pause for 15 seconds and the pain would subside. So I still ran, just lopping off a few miles each day. And finally I went to see a cardiologist who put me on a treadmill until the ST segments dropped and then he stopped me with an ominous “the test has gone positive.” What does a cardiologist do when his middle-aged physician friend has a positive treadmill test? An angiogram of course. So we soon had pictures of my coronary arteries and yes, there were blockages, but not very severe, maybe I could keep jogging.

It took a few years for the angina to become really disruptive. Another angiogram led to an effort to open up the main obstruction, one-half way down the anterior descending artery, known familiarly as “the artery of sudden death.” OK, let’s do something! And that something was a stent, placed with difficulty and a great deal of chest pain. I think my 2 (now 2 to do this difficult procedure) cardiologists were fearful that they would end with a patent vessel and a dead patient. After the procedure I noted no change in the chest pain trouble but surprise, a belated blood count showed an anemia. So we treated the anemia and the angina got better. I began to wonder if we could have avoided the stenting if we had just checked a hematocrit before the angiogram. But of course, insurance didn’t include that test for that diagnosis.

That was a dozen years ago and the angina remained but at a very stable level. Some of our young physician colleagues use that word “Stable” to mean something that will probably not kill you in the next hour or two. I prefer to use it to mean unchanging. And the angina remained but didn’t change. I had to give up running, a terrible loss for me, but I could walk and do some gym work. I could still read and write and play bridge. Jogging a block or two was enough to bring on the familiar pain; I could give up the jogging.

Then, a year ago the dam broke. My angina increased. Instead of a mile fast walk to provoke it, now a block’s walking did it. And recovery that used to take a few seconds now took a minute or two. We were in Buenos Aires, a city with lots of easy hills, but no longer so easy for me. So I thought it time to go back to the cardiologist. Another angiogram surprised him and me both. The old left coronary artery with its stent was perfectly open, but the right occluded at its orifice and the good Dr. Rainwater couldn’t open it with any of his catheters, wires, or brushes. I needed a real operation, a coronary bypass to that right coronary artery. Not my favorite idea. Joe sent me to a surgeon who he said had the best results in Denver.

Those surgeons love to do what they know how to do. A man with a hammer sees everything as a nail. The surgeon saw me as a bypassable artery.

Big things can be awfully easy to do. I was in and out of the hospital with a nice new bypass in a few days. And though depleted of strength by this strange attack, I happily did not have a pump brain, could still sort a bridge hand, and began my exercise rehabilitation. Within a few weeks I saw hope of regaining strength and no angina. A chance to cut indeed had been a chance to cure.

That was January. Summer spent up in the mountains at 9000 feet, lots of walking, some easy hikes, doing well. And then, all of a sudden, my heart rhythm changed. Frequent premature ventricular beats, often paired to sinus beats (bigemini), sometimes in triplets (trigeminy.) And worse still, I no longer could walk around the block, my usual 3/8 mile with the little dogs had to stop several times with faintness and then with pain. The angina was back, with a vengeance.

So once again to the cardiologist. He and I discussed the odds. 70% probable: something had plugged up, maybe the new graft. If so, he thought I would have to go elsewhere, perhaps to Scripps in San Diego, where people were better at un-plugging vessels with tubes and wires. 5% possibility: plugged vessel that Joe could clear up. That left about a 30% probability: maybe vessels would be OK but it was the fault of the new arrhythmia. And ventricular arrhythmias are notoriously tough to treat. Antiarrhythmia drugs are also all pro-arrhythmic. The treatment may be worse than the disease. I might have become a cardiac cripple.

This was my fourth cardiac angiogram. It seems true that we spend most of our medical expenses in the last year or two of our lives. Maybe that’s where I am. But I agreed—we had to know what was causing the problem even though I didn’t want more dye squirted into my vessels. Well, big surprise and a pleasing one: the coronary vessels were wide open. It was the PVCs that were causing the trouble. So Joe asked Charlie, his electrophysiology pal, to come look at me. Charlie arrived full of joy. He had just the trick. He could stick a few wires into my left ventricle and fry the place that originated the extra beats. How sure was he? Oh, maybe 90% sure—if the wires didn’t perforate the heart wall and if he fried the right spot, maybe I’d be better. Oh? I wondered if there weren’t any drugs, any pills to try first. Yes, he grudgingly admitted, but seldom successfully. Well, let’s try.

The nurse brought me a single pill, approved for treating atrial arrhythmias, not the ventricular extra beats that were attacking me. But nonetheless, 2 hours later an ECG showed 3 PVCs per minute. There had been 30 before. The new drug works! Hooray!

And the coffee had been great.

But I want to tell you about the 2 days in the hospital, when my nurse Susan told me what she had figured out. Her father was a physician, in fact, a fellow I knew well. He had cancer and was suffering chemotherapy. She said that the hardest part for him was giving up control. “You doctors are used to being in charge,” she said. “Now you’re gone over to the other side.” That was it. The total loss of control—of my chest pain, of the cardiac arrhythmia, even of the head of the bed and a late breakfast. That coffee was the worst. I didn’t want decaf.

Once understood by Susan and then even by me, the loss of control seemed less painful. And now the PVCs are almost gone, the chest pain has vanished, and I’m back to walking my 2 little dogs a half a mile 3 times a day.

Corresponding author: Frederic W. Platt, MD, 396 Steele St., Denver, CO 80206, plattf@hotmail.com.

It was the coffee that did it to me. “You can’t have real coffee,” the room service dietary person said, “decaf. You’re on a cardiac diet.” She had already refused my request for orange juice, for waffles, for a short stack of pancakes—“You’re on a diabetic diet.” But, I remonstrated, my sugars are normal and at home I eat a regular diet. “Not on your life,” she replied. You have to get your doctor or your nurse to change the diet order. “You’re on a cardiac-diabetic diet.” But I’ve talked with my cardiologist and he says a couple of cups of coffee a day are OK. “Nope, not from us, it isn’t.”

My last meal was the evening before. Nothing to speak of for breakfast and then no lunch, of course, since my cardiac angiogram had been scheduled for 2:30 pm and then started an hour late. It was now dinner time and I was famished. I especially wanted that cup of coffee. My doctor had gone back to his office and in a hospital staffed with many many nursing people, I didn’t know who my nurse was. Worse yet, I had sent my eyeglasses home with my wife along with my clothes. I couldn’t see the button to summon help (although it wouldn’t have been much help, I also couldn’t see the TV up on the wall). Besides, flat on my back, after strict instructions to lie flat for 12 hours after the angiogram femoral stick, I couldn’t even find the nurse call button.

I tried pulling rank. “I’m a doctor myself, you know.” No luck. The dietary limb of this new hospital stood firm.

Eventually, many hours later (maybe ¾ of an hour), maybe days later, my real nurse came in. She introduced herself, “Susan,” and told me she was to be “my main man” and that “she had the keys to the kingdom.” Specifically, she could change the dietary order. Breakfast appeared at 8 pm. Yum! Real coffee, not decaf.

I was in the hospital to figure out why my angina pectoris had returned.

It arrived about 20 years ago. A diminution in the distance I could run without stopping because of a new sensation, a heavy rock in my chest. No big problem; I could pause for 15 seconds and the pain would subside. So I still ran, just lopping off a few miles each day. And finally I went to see a cardiologist who put me on a treadmill until the ST segments dropped and then he stopped me with an ominous “the test has gone positive.” What does a cardiologist do when his middle-aged physician friend has a positive treadmill test? An angiogram of course. So we soon had pictures of my coronary arteries and yes, there were blockages, but not very severe, maybe I could keep jogging.

It took a few years for the angina to become really disruptive. Another angiogram led to an effort to open up the main obstruction, one-half way down the anterior descending artery, known familiarly as “the artery of sudden death.” OK, let’s do something! And that something was a stent, placed with difficulty and a great deal of chest pain. I think my 2 (now 2 to do this difficult procedure) cardiologists were fearful that they would end with a patent vessel and a dead patient. After the procedure I noted no change in the chest pain trouble but surprise, a belated blood count showed an anemia. So we treated the anemia and the angina got better. I began to wonder if we could have avoided the stenting if we had just checked a hematocrit before the angiogram. But of course, insurance didn’t include that test for that diagnosis.

That was a dozen years ago and the angina remained but at a very stable level. Some of our young physician colleagues use that word “Stable” to mean something that will probably not kill you in the next hour or two. I prefer to use it to mean unchanging. And the angina remained but didn’t change. I had to give up running, a terrible loss for me, but I could walk and do some gym work. I could still read and write and play bridge. Jogging a block or two was enough to bring on the familiar pain; I could give up the jogging.

Then, a year ago the dam broke. My angina increased. Instead of a mile fast walk to provoke it, now a block’s walking did it. And recovery that used to take a few seconds now took a minute or two. We were in Buenos Aires, a city with lots of easy hills, but no longer so easy for me. So I thought it time to go back to the cardiologist. Another angiogram surprised him and me both. The old left coronary artery with its stent was perfectly open, but the right occluded at its orifice and the good Dr. Rainwater couldn’t open it with any of his catheters, wires, or brushes. I needed a real operation, a coronary bypass to that right coronary artery. Not my favorite idea. Joe sent me to a surgeon who he said had the best results in Denver.

Those surgeons love to do what they know how to do. A man with a hammer sees everything as a nail. The surgeon saw me as a bypassable artery.

Big things can be awfully easy to do. I was in and out of the hospital with a nice new bypass in a few days. And though depleted of strength by this strange attack, I happily did not have a pump brain, could still sort a bridge hand, and began my exercise rehabilitation. Within a few weeks I saw hope of regaining strength and no angina. A chance to cut indeed had been a chance to cure.

That was January. Summer spent up in the mountains at 9000 feet, lots of walking, some easy hikes, doing well. And then, all of a sudden, my heart rhythm changed. Frequent premature ventricular beats, often paired to sinus beats (bigemini), sometimes in triplets (trigeminy.) And worse still, I no longer could walk around the block, my usual 3/8 mile with the little dogs had to stop several times with faintness and then with pain. The angina was back, with a vengeance.

So once again to the cardiologist. He and I discussed the odds. 70% probable: something had plugged up, maybe the new graft. If so, he thought I would have to go elsewhere, perhaps to Scripps in San Diego, where people were better at un-plugging vessels with tubes and wires. 5% possibility: plugged vessel that Joe could clear up. That left about a 30% probability: maybe vessels would be OK but it was the fault of the new arrhythmia. And ventricular arrhythmias are notoriously tough to treat. Antiarrhythmia drugs are also all pro-arrhythmic. The treatment may be worse than the disease. I might have become a cardiac cripple.

This was my fourth cardiac angiogram. It seems true that we spend most of our medical expenses in the last year or two of our lives. Maybe that’s where I am. But I agreed—we had to know what was causing the problem even though I didn’t want more dye squirted into my vessels. Well, big surprise and a pleasing one: the coronary vessels were wide open. It was the PVCs that were causing the trouble. So Joe asked Charlie, his electrophysiology pal, to come look at me. Charlie arrived full of joy. He had just the trick. He could stick a few wires into my left ventricle and fry the place that originated the extra beats. How sure was he? Oh, maybe 90% sure—if the wires didn’t perforate the heart wall and if he fried the right spot, maybe I’d be better. Oh? I wondered if there weren’t any drugs, any pills to try first. Yes, he grudgingly admitted, but seldom successfully. Well, let’s try.

The nurse brought me a single pill, approved for treating atrial arrhythmias, not the ventricular extra beats that were attacking me. But nonetheless, 2 hours later an ECG showed 3 PVCs per minute. There had been 30 before. The new drug works! Hooray!

And the coffee had been great.

But I want to tell you about the 2 days in the hospital, when my nurse Susan told me what she had figured out. Her father was a physician, in fact, a fellow I knew well. He had cancer and was suffering chemotherapy. She said that the hardest part for him was giving up control. “You doctors are used to being in charge,” she said. “Now you’re gone over to the other side.” That was it. The total loss of control—of my chest pain, of the cardiac arrhythmia, even of the head of the bed and a late breakfast. That coffee was the worst. I didn’t want decaf.

Once understood by Susan and then even by me, the loss of control seemed less painful. And now the PVCs are almost gone, the chest pain has vanished, and I’m back to walking my 2 little dogs a half a mile 3 times a day.

Corresponding author: Frederic W. Platt, MD, 396 Steele St., Denver, CO 80206, plattf@hotmail.com.

It was the coffee that did it to me. “You can’t have real coffee,” the room service dietary person said, “decaf. You’re on a cardiac diet.” She had already refused my request for orange juice, for waffles, for a short stack of pancakes—“You’re on a diabetic diet.” But, I remonstrated, my sugars are normal and at home I eat a regular diet. “Not on your life,” she replied. You have to get your doctor or your nurse to change the diet order. “You’re on a cardiac-diabetic diet.” But I’ve talked with my cardiologist and he says a couple of cups of coffee a day are OK. “Nope, not from us, it isn’t.”

My last meal was the evening before. Nothing to speak of for breakfast and then no lunch, of course, since my cardiac angiogram had been scheduled for 2:30 pm and then started an hour late. It was now dinner time and I was famished. I especially wanted that cup of coffee. My doctor had gone back to his office and in a hospital staffed with many many nursing people, I didn’t know who my nurse was. Worse yet, I had sent my eyeglasses home with my wife along with my clothes. I couldn’t see the button to summon help (although it wouldn’t have been much help, I also couldn’t see the TV up on the wall). Besides, flat on my back, after strict instructions to lie flat for 12 hours after the angiogram femoral stick, I couldn’t even find the nurse call button.

I tried pulling rank. “I’m a doctor myself, you know.” No luck. The dietary limb of this new hospital stood firm.

Eventually, many hours later (maybe ¾ of an hour), maybe days later, my real nurse came in. She introduced herself, “Susan,” and told me she was to be “my main man” and that “she had the keys to the kingdom.” Specifically, she could change the dietary order. Breakfast appeared at 8 pm. Yum! Real coffee, not decaf.

I was in the hospital to figure out why my angina pectoris had returned.

It arrived about 20 years ago. A diminution in the distance I could run without stopping because of a new sensation, a heavy rock in my chest. No big problem; I could pause for 15 seconds and the pain would subside. So I still ran, just lopping off a few miles each day. And finally I went to see a cardiologist who put me on a treadmill until the ST segments dropped and then he stopped me with an ominous “the test has gone positive.” What does a cardiologist do when his middle-aged physician friend has a positive treadmill test? An angiogram of course. So we soon had pictures of my coronary arteries and yes, there were blockages, but not very severe, maybe I could keep jogging.

It took a few years for the angina to become really disruptive. Another angiogram led to an effort to open up the main obstruction, one-half way down the anterior descending artery, known familiarly as “the artery of sudden death.” OK, let’s do something! And that something was a stent, placed with difficulty and a great deal of chest pain. I think my 2 (now 2 to do this difficult procedure) cardiologists were fearful that they would end with a patent vessel and a dead patient. After the procedure I noted no change in the chest pain trouble but surprise, a belated blood count showed an anemia. So we treated the anemia and the angina got better. I began to wonder if we could have avoided the stenting if we had just checked a hematocrit before the angiogram. But of course, insurance didn’t include that test for that diagnosis.

That was a dozen years ago and the angina remained but at a very stable level. Some of our young physician colleagues use that word “Stable” to mean something that will probably not kill you in the next hour or two. I prefer to use it to mean unchanging. And the angina remained but didn’t change. I had to give up running, a terrible loss for me, but I could walk and do some gym work. I could still read and write and play bridge. Jogging a block or two was enough to bring on the familiar pain; I could give up the jogging.

Then, a year ago the dam broke. My angina increased. Instead of a mile fast walk to provoke it, now a block’s walking did it. And recovery that used to take a few seconds now took a minute or two. We were in Buenos Aires, a city with lots of easy hills, but no longer so easy for me. So I thought it time to go back to the cardiologist. Another angiogram surprised him and me both. The old left coronary artery with its stent was perfectly open, but the right occluded at its orifice and the good Dr. Rainwater couldn’t open it with any of his catheters, wires, or brushes. I needed a real operation, a coronary bypass to that right coronary artery. Not my favorite idea. Joe sent me to a surgeon who he said had the best results in Denver.

Those surgeons love to do what they know how to do. A man with a hammer sees everything as a nail. The surgeon saw me as a bypassable artery.

Big things can be awfully easy to do. I was in and out of the hospital with a nice new bypass in a few days. And though depleted of strength by this strange attack, I happily did not have a pump brain, could still sort a bridge hand, and began my exercise rehabilitation. Within a few weeks I saw hope of regaining strength and no angina. A chance to cut indeed had been a chance to cure.

That was January. Summer spent up in the mountains at 9000 feet, lots of walking, some easy hikes, doing well. And then, all of a sudden, my heart rhythm changed. Frequent premature ventricular beats, often paired to sinus beats (bigemini), sometimes in triplets (trigeminy.) And worse still, I no longer could walk around the block, my usual 3/8 mile with the little dogs had to stop several times with faintness and then with pain. The angina was back, with a vengeance.

So once again to the cardiologist. He and I discussed the odds. 70% probable: something had plugged up, maybe the new graft. If so, he thought I would have to go elsewhere, perhaps to Scripps in San Diego, where people were better at un-plugging vessels with tubes and wires. 5% possibility: plugged vessel that Joe could clear up. That left about a 30% probability: maybe vessels would be OK but it was the fault of the new arrhythmia. And ventricular arrhythmias are notoriously tough to treat. Antiarrhythmia drugs are also all pro-arrhythmic. The treatment may be worse than the disease. I might have become a cardiac cripple.

This was my fourth cardiac angiogram. It seems true that we spend most of our medical expenses in the last year or two of our lives. Maybe that’s where I am. But I agreed—we had to know what was causing the problem even though I didn’t want more dye squirted into my vessels. Well, big surprise and a pleasing one: the coronary vessels were wide open. It was the PVCs that were causing the trouble. So Joe asked Charlie, his electrophysiology pal, to come look at me. Charlie arrived full of joy. He had just the trick. He could stick a few wires into my left ventricle and fry the place that originated the extra beats. How sure was he? Oh, maybe 90% sure—if the wires didn’t perforate the heart wall and if he fried the right spot, maybe I’d be better. Oh? I wondered if there weren’t any drugs, any pills to try first. Yes, he grudgingly admitted, but seldom successfully. Well, let’s try.

The nurse brought me a single pill, approved for treating atrial arrhythmias, not the ventricular extra beats that were attacking me. But nonetheless, 2 hours later an ECG showed 3 PVCs per minute. There had been 30 before. The new drug works! Hooray!

And the coffee had been great.

But I want to tell you about the 2 days in the hospital, when my nurse Susan told me what she had figured out. Her father was a physician, in fact, a fellow I knew well. He had cancer and was suffering chemotherapy. She said that the hardest part for him was giving up control. “You doctors are used to being in charge,” she said. “Now you’re gone over to the other side.” That was it. The total loss of control—of my chest pain, of the cardiac arrhythmia, even of the head of the bed and a late breakfast. That coffee was the worst. I didn’t want decaf.

Once understood by Susan and then even by me, the loss of control seemed less painful. And now the PVCs are almost gone, the chest pain has vanished, and I’m back to walking my 2 little dogs a half a mile 3 times a day.

Corresponding author: Frederic W. Platt, MD, 396 Steele St., Denver, CO 80206, plattf@hotmail.com.

In our last column, we highlighted the Rio Grande Valley Health Alliance, an accountable care organization in McAllen, Tex., composed of 14 independent primary care physicians in 11 practices. As primary care physicians, the RGVHA providers realized the potential for a primary care ACO to generate savings from value-based care.

Because RGVHA is a network model ACO – the physicians stay in their separate independent practices but participate in the ACO through contracts – RGVHA needed a way to manage the ACO data collection, sorting, and reporting requirements in an efficient and effective manner.

Fortunately, Dr. Gretchen Hoyle of MD Online Solutions was able to tailor a data management solution for RGVHA. In addition, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Through Dr. Hoyle’s data collection and interpretation work with RGVHA, the ACO now has concrete data showing utilization trends and patterns. The most positive result has been the demonstrated benefit of nurse care coordinators, who work with patients in the post–acute care settings between their office visits.

In fact, care coordinators have proved to be RGVHA’s secret weapon, because their work has been invaluable in managing patients with chronic conditions between provider appointments.

Conversely, the data have revealed a pattern of overuse of home health care services, which helps contribute to higher care costs overall, making home health the biggest disappointment.

The secret weapon

As Dr. Hoyle so aptly said, "To become a fully functioning ACO, an organization must be able to address both sides of the ACO ‘coin’: quality improvement and cost control." Care coordinators have the capacity to address both concerns.

Within RGVHA, care coordinators have performed chart reviews that identify the ACO’s current performance according to the Centers for Medicare and Medicaid Services’ quality standards. This is the first secret weapon for a small primary care ACO.

This data collection helps RGVHA fill in knowledge gaps as it works toward having a fully integrated electronic health records system. In turn, it helps the care coordinators identify the strengths and weaknesses of each of the participating ACO providers. This ensures that weaknesses can be addressed in a timely fashion. In addition, the chart reviews help identify documentation issues. Documentation is critical to meeting CMS benchmarks, which ultimately helps determine the amount of shared savings for an ACO.

In addition, the data have proved crucial to being able to rank patients by cost. That has allowed RGVHA to identify the top 10% of patients whose care accounts for 50% of the total care costs in the ACO. This information allows providers to understand which patients and types of patients are more expensive, and who can benefit most from intense care coordination and/or longer visits with RGVHA’s primary care doctors.

Claims data show that even a small amount of additional time and care coordination outside of the clinic setting curbs utilization for the most complex patients and saves money. Most important, care coordinators help providers focus their time and energy where it can have the most impact.

The biggest disappointment

Shortly after RGVHA began reviewing patient claims data, home health care costs per patient emerged as one of the greatest cost outliers. The data revealed that providers outside of the ACO were prescribing home health at much higher rates than providers within the ACO. A subsequent gap analysis showed that home health was a prime opportunity target for RGVHA.

As RGVHA developed a strategy to address the overutilization and extremely high home health costs for their patient population, the providers faced their biggest disappointment to date: The Medicare Shared Savings Program regulations only permit ACOs to "ask" that providers outside the ACO coordinate patient care with doctors inside the ACO, not "tell" the providers that they must collaborate in delivering evidence-based, high-value care.

So, RGVHA decided to use those data as the starting point to reach out to those providers.

Dr. Hoyle helped RGVHA identify the amount of home health care generated by each specific agency and ordering physician. That information was used to craft a targeted letter to each provider outside the ACO requesting and encouraging their collaboration and cooperation in the development of a care plan for each home health patient.

Now, several months later, home health care overutilization and costs are beginning to decline, as patient care is monitored by RGVHA and appropriately coordinated among each ACO patient’s team of care providers.

RGVHA’s biggest concern has now become one of its biggest assets. The ACO doctors finally feel empowered in their ability to impact the quality and costs of patient care. Furthermore, they are excited they are getting paid for doing what they are trained to do: provide high-value care to their patients.

The good news is that, when properly informed and invited to help shape high-value patient care, providers want to and will do the right thing.

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. Mr. Bobbitt is grateful for the excellent lead research and drafting of this article by Ms. Poe. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.

In our last column, we highlighted the Rio Grande Valley Health Alliance, an accountable care organization in McAllen, Tex., composed of 14 independent primary care physicians in 11 practices. As primary care physicians, the RGVHA providers realized the potential for a primary care ACO to generate savings from value-based care.

Because RGVHA is a network model ACO – the physicians stay in their separate independent practices but participate in the ACO through contracts – RGVHA needed a way to manage the ACO data collection, sorting, and reporting requirements in an efficient and effective manner.

Fortunately, Dr. Gretchen Hoyle of MD Online Solutions was able to tailor a data management solution for RGVHA. In addition, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Through Dr. Hoyle’s data collection and interpretation work with RGVHA, the ACO now has concrete data showing utilization trends and patterns. The most positive result has been the demonstrated benefit of nurse care coordinators, who work with patients in the post–acute care settings between their office visits.

In fact, care coordinators have proved to be RGVHA’s secret weapon, because their work has been invaluable in managing patients with chronic conditions between provider appointments.

Conversely, the data have revealed a pattern of overuse of home health care services, which helps contribute to higher care costs overall, making home health the biggest disappointment.

The secret weapon

As Dr. Hoyle so aptly said, "To become a fully functioning ACO, an organization must be able to address both sides of the ACO ‘coin’: quality improvement and cost control." Care coordinators have the capacity to address both concerns.

Within RGVHA, care coordinators have performed chart reviews that identify the ACO’s current performance according to the Centers for Medicare and Medicaid Services’ quality standards. This is the first secret weapon for a small primary care ACO.

This data collection helps RGVHA fill in knowledge gaps as it works toward having a fully integrated electronic health records system. In turn, it helps the care coordinators identify the strengths and weaknesses of each of the participating ACO providers. This ensures that weaknesses can be addressed in a timely fashion. In addition, the chart reviews help identify documentation issues. Documentation is critical to meeting CMS benchmarks, which ultimately helps determine the amount of shared savings for an ACO.

In addition, the data have proved crucial to being able to rank patients by cost. That has allowed RGVHA to identify the top 10% of patients whose care accounts for 50% of the total care costs in the ACO. This information allows providers to understand which patients and types of patients are more expensive, and who can benefit most from intense care coordination and/or longer visits with RGVHA’s primary care doctors.

Claims data show that even a small amount of additional time and care coordination outside of the clinic setting curbs utilization for the most complex patients and saves money. Most important, care coordinators help providers focus their time and energy where it can have the most impact.

The biggest disappointment

Shortly after RGVHA began reviewing patient claims data, home health care costs per patient emerged as one of the greatest cost outliers. The data revealed that providers outside of the ACO were prescribing home health at much higher rates than providers within the ACO. A subsequent gap analysis showed that home health was a prime opportunity target for RGVHA.

As RGVHA developed a strategy to address the overutilization and extremely high home health costs for their patient population, the providers faced their biggest disappointment to date: The Medicare Shared Savings Program regulations only permit ACOs to "ask" that providers outside the ACO coordinate patient care with doctors inside the ACO, not "tell" the providers that they must collaborate in delivering evidence-based, high-value care.

So, RGVHA decided to use those data as the starting point to reach out to those providers.

Dr. Hoyle helped RGVHA identify the amount of home health care generated by each specific agency and ordering physician. That information was used to craft a targeted letter to each provider outside the ACO requesting and encouraging their collaboration and cooperation in the development of a care plan for each home health patient.

Now, several months later, home health care overutilization and costs are beginning to decline, as patient care is monitored by RGVHA and appropriately coordinated among each ACO patient’s team of care providers.

RGVHA’s biggest concern has now become one of its biggest assets. The ACO doctors finally feel empowered in their ability to impact the quality and costs of patient care. Furthermore, they are excited they are getting paid for doing what they are trained to do: provide high-value care to their patients.

The good news is that, when properly informed and invited to help shape high-value patient care, providers want to and will do the right thing.

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. Mr. Bobbitt is grateful for the excellent lead research and drafting of this article by Ms. Poe. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.

In our last column, we highlighted the Rio Grande Valley Health Alliance, an accountable care organization in McAllen, Tex., composed of 14 independent primary care physicians in 11 practices. As primary care physicians, the RGVHA providers realized the potential for a primary care ACO to generate savings from value-based care.

Because RGVHA is a network model ACO – the physicians stay in their separate independent practices but participate in the ACO through contracts – RGVHA needed a way to manage the ACO data collection, sorting, and reporting requirements in an efficient and effective manner.

Fortunately, Dr. Gretchen Hoyle of MD Online Solutions was able to tailor a data management solution for RGVHA. In addition, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Through Dr. Hoyle’s data collection and interpretation work with RGVHA, the ACO now has concrete data showing utilization trends and patterns. The most positive result has been the demonstrated benefit of nurse care coordinators, who work with patients in the post–acute care settings between their office visits.

In fact, care coordinators have proved to be RGVHA’s secret weapon, because their work has been invaluable in managing patients with chronic conditions between provider appointments.

Conversely, the data have revealed a pattern of overuse of home health care services, which helps contribute to higher care costs overall, making home health the biggest disappointment.

The secret weapon

As Dr. Hoyle so aptly said, "To become a fully functioning ACO, an organization must be able to address both sides of the ACO ‘coin’: quality improvement and cost control." Care coordinators have the capacity to address both concerns.

Within RGVHA, care coordinators have performed chart reviews that identify the ACO’s current performance according to the Centers for Medicare and Medicaid Services’ quality standards. This is the first secret weapon for a small primary care ACO.

This data collection helps RGVHA fill in knowledge gaps as it works toward having a fully integrated electronic health records system. In turn, it helps the care coordinators identify the strengths and weaknesses of each of the participating ACO providers. This ensures that weaknesses can be addressed in a timely fashion. In addition, the chart reviews help identify documentation issues. Documentation is critical to meeting CMS benchmarks, which ultimately helps determine the amount of shared savings for an ACO.

In addition, the data have proved crucial to being able to rank patients by cost. That has allowed RGVHA to identify the top 10% of patients whose care accounts for 50% of the total care costs in the ACO. This information allows providers to understand which patients and types of patients are more expensive, and who can benefit most from intense care coordination and/or longer visits with RGVHA’s primary care doctors.

Claims data show that even a small amount of additional time and care coordination outside of the clinic setting curbs utilization for the most complex patients and saves money. Most important, care coordinators help providers focus their time and energy where it can have the most impact.

The biggest disappointment

Shortly after RGVHA began reviewing patient claims data, home health care costs per patient emerged as one of the greatest cost outliers. The data revealed that providers outside of the ACO were prescribing home health at much higher rates than providers within the ACO. A subsequent gap analysis showed that home health was a prime opportunity target for RGVHA.

As RGVHA developed a strategy to address the overutilization and extremely high home health costs for their patient population, the providers faced their biggest disappointment to date: The Medicare Shared Savings Program regulations only permit ACOs to "ask" that providers outside the ACO coordinate patient care with doctors inside the ACO, not "tell" the providers that they must collaborate in delivering evidence-based, high-value care.

So, RGVHA decided to use those data as the starting point to reach out to those providers.

Dr. Hoyle helped RGVHA identify the amount of home health care generated by each specific agency and ordering physician. That information was used to craft a targeted letter to each provider outside the ACO requesting and encouraging their collaboration and cooperation in the development of a care plan for each home health patient.

Now, several months later, home health care overutilization and costs are beginning to decline, as patient care is monitored by RGVHA and appropriately coordinated among each ACO patient’s team of care providers.

RGVHA’s biggest concern has now become one of its biggest assets. The ACO doctors finally feel empowered in their ability to impact the quality and costs of patient care. Furthermore, they are excited they are getting paid for doing what they are trained to do: provide high-value care to their patients.

The good news is that, when properly informed and invited to help shape high-value patient care, providers want to and will do the right thing.

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. Mr. Bobbitt is grateful for the excellent lead research and drafting of this article by Ms. Poe. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.

While concepts and theories can go a long way, sometimes the best way to understand something is through a concrete example.

So, from time to time, ACO Insider will check in on a new accountable care organization composed of 14 independent physicians in 11 practices in McAllen, Tex.

We chose them because they share many of the same questions and concerns as quite a few of you readers: Will this work? Where do I begin? How can we do this, since we have no free time or money? How much will this cost? Will there be any shared savings? Do we have to affiliate with a hospital or a large practice? Are we too small? How do we apply for the Medicare Shared Savings Program (MSSP)? What will change in my practice?

The name of the ACO is Rio Grande Valley Health Alliance (RGVHA). It was formed in January 2012 as a "network-model" ACO, meaning that the physicians stay in their separate independent practices but participate in the ACO through contract. Its first – and as of this writing, only – ACO payer contract is with Medicare, the MSSP.

So far, there have been a number of unexpected highs and a number of unexpected lows. The primary care physicians of RGVHA hope that by sharing their story, they can help you better navigate your own ACO course.

Opportunity for primary care

Dr. Luis Delgado became intrigued by the possibility under accountable care of rewarding primary care physicians for the savings they generate while maintaining or improving quality. Instead of resisting change, he saw opportunity.

He also saw a chance to do something about McAllen’s reputation, gained through Dr. Atul Gawande’s 2009 article in the New Yorker entitled, "The Cost Conundrum." That article focused on McAllen’s Medicare health costs, which were almost twice those of its Rio Grande River neighbor, El Paso.

However, beyond having a vision, he had no know-how and no budget.

Fortunately, as readers of this column know, there is so much documented "low-hanging fruit" for primary care to generate savings through value-based care that the strategic time and expertise expenditures proved not to be significant. The legal structure and backroom business logistics for a small network-model primary care physician ACO are also relatively straightforward. RGVHA has two full-time administrative staffers, one part-time president (Dr. Delgado), and one part-time medical director (Dr. Roger Heredia).

However, the new ACO data collection, sorting, and reporting requirements were somewhat daunting – that is, until they met Dr. Gretchen Hoyle of MD Online Solutions (MDOS). Dr. Hoyle is a practicing pediatrician who spearheaded the design of a physician-friendly care management data system for her practice and found it ideal for the accountable care era. Her company targets small- to medium-sized physician-led ACOs.

MDOS was able to tailor a nimble ACO solution scaled to RGVHA’s needs, thus allowing RGVHA to supply its last missing piece in a cost-effective manner. Because she is a practicing physician, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Approved for the Medicare ACO

Despite initial fears, RGVHA found that the MSSP application process was not intimidating at all. It turned out to be a reflection of its business structure and primary care physician ACO strategy.

"If you get your game plan together ahead of time, independent primary care physicians should be successful in applying for the Medicare Shared Savings Program," stated Dr. Delgado. "We found that Medicare is supportive of this type of ACO, I guess because it sees their potential to improve health care," he said.

The Centers for Medicare & Medicaid Services does indeed support these types of ACOs, as RGVHA qualified for one of the last Advanced Payment Program grants. The CMS is so confident that these physician-led, nonmetropolitan ACOs will work, that the agency actually fronted the infrastructure and operational money to them. RGVHA was one of the last grantees of this one-time appropriation.

They began the MSSP program Jan. 1, 2013, opting not to take risk and to receive 50% of the savings they generated for the 5,000 patients attributed to them, if quality and patient satisfaction metrics are met.

‘I haven’t had this much fun practicing medicine in 10 years!’

To decide what type of initiatives to undertake, the physicians read the Physician’s Accountable Care Toolkit (profiled in an earlier column) and convened a weekend workshop. They were pleasantly surprised when they realized that so many savings and quality improvement opportunities are available to primary care physicians under accountable care – and control over the physician-patient relationship was being returned to them.

They targeted diabetes management, patient engagement, best practices for enhanced prevention and wellness, and home health management.

One physician summed up the mood when she exclaimed, "I haven’t had this much fun practicing medicine in 10 years."

As they celebrate their first year under the MSSP, how are they doing? Check in next month for part 2: Our secret weapon, and our biggest disappointment.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians in forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.

While concepts and theories can go a long way, sometimes the best way to understand something is through a concrete example.

So, from time to time, ACO Insider will check in on a new accountable care organization composed of 14 independent physicians in 11 practices in McAllen, Tex.

We chose them because they share many of the same questions and concerns as quite a few of you readers: Will this work? Where do I begin? How can we do this, since we have no free time or money? How much will this cost? Will there be any shared savings? Do we have to affiliate with a hospital or a large practice? Are we too small? How do we apply for the Medicare Shared Savings Program (MSSP)? What will change in my practice?

The name of the ACO is Rio Grande Valley Health Alliance (RGVHA). It was formed in January 2012 as a "network-model" ACO, meaning that the physicians stay in their separate independent practices but participate in the ACO through contract. Its first – and as of this writing, only – ACO payer contract is with Medicare, the MSSP.

So far, there have been a number of unexpected highs and a number of unexpected lows. The primary care physicians of RGVHA hope that by sharing their story, they can help you better navigate your own ACO course.

Opportunity for primary care

Dr. Luis Delgado became intrigued by the possibility under accountable care of rewarding primary care physicians for the savings they generate while maintaining or improving quality. Instead of resisting change, he saw opportunity.

He also saw a chance to do something about McAllen’s reputation, gained through Dr. Atul Gawande’s 2009 article in the New Yorker entitled, "The Cost Conundrum." That article focused on McAllen’s Medicare health costs, which were almost twice those of its Rio Grande River neighbor, El Paso.

However, beyond having a vision, he had no know-how and no budget.

Fortunately, as readers of this column know, there is so much documented "low-hanging fruit" for primary care to generate savings through value-based care that the strategic time and expertise expenditures proved not to be significant. The legal structure and backroom business logistics for a small network-model primary care physician ACO are also relatively straightforward. RGVHA has two full-time administrative staffers, one part-time president (Dr. Delgado), and one part-time medical director (Dr. Roger Heredia).

However, the new ACO data collection, sorting, and reporting requirements were somewhat daunting – that is, until they met Dr. Gretchen Hoyle of MD Online Solutions (MDOS). Dr. Hoyle is a practicing pediatrician who spearheaded the design of a physician-friendly care management data system for her practice and found it ideal for the accountable care era. Her company targets small- to medium-sized physician-led ACOs.

MDOS was able to tailor a nimble ACO solution scaled to RGVHA’s needs, thus allowing RGVHA to supply its last missing piece in a cost-effective manner. Because she is a practicing physician, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Approved for the Medicare ACO

Despite initial fears, RGVHA found that the MSSP application process was not intimidating at all. It turned out to be a reflection of its business structure and primary care physician ACO strategy.

"If you get your game plan together ahead of time, independent primary care physicians should be successful in applying for the Medicare Shared Savings Program," stated Dr. Delgado. "We found that Medicare is supportive of this type of ACO, I guess because it sees their potential to improve health care," he said.

The Centers for Medicare & Medicaid Services does indeed support these types of ACOs, as RGVHA qualified for one of the last Advanced Payment Program grants. The CMS is so confident that these physician-led, nonmetropolitan ACOs will work, that the agency actually fronted the infrastructure and operational money to them. RGVHA was one of the last grantees of this one-time appropriation.

They began the MSSP program Jan. 1, 2013, opting not to take risk and to receive 50% of the savings they generated for the 5,000 patients attributed to them, if quality and patient satisfaction metrics are met.

‘I haven’t had this much fun practicing medicine in 10 years!’

To decide what type of initiatives to undertake, the physicians read the Physician’s Accountable Care Toolkit (profiled in an earlier column) and convened a weekend workshop. They were pleasantly surprised when they realized that so many savings and quality improvement opportunities are available to primary care physicians under accountable care – and control over the physician-patient relationship was being returned to them.

They targeted diabetes management, patient engagement, best practices for enhanced prevention and wellness, and home health management.

One physician summed up the mood when she exclaimed, "I haven’t had this much fun practicing medicine in 10 years."

As they celebrate their first year under the MSSP, how are they doing? Check in next month for part 2: Our secret weapon, and our biggest disappointment.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians in forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.

While concepts and theories can go a long way, sometimes the best way to understand something is through a concrete example.

So, from time to time, ACO Insider will check in on a new accountable care organization composed of 14 independent physicians in 11 practices in McAllen, Tex.

We chose them because they share many of the same questions and concerns as quite a few of you readers: Will this work? Where do I begin? How can we do this, since we have no free time or money? How much will this cost? Will there be any shared savings? Do we have to affiliate with a hospital or a large practice? Are we too small? How do we apply for the Medicare Shared Savings Program (MSSP)? What will change in my practice?

The name of the ACO is Rio Grande Valley Health Alliance (RGVHA). It was formed in January 2012 as a "network-model" ACO, meaning that the physicians stay in their separate independent practices but participate in the ACO through contract. Its first – and as of this writing, only – ACO payer contract is with Medicare, the MSSP.

So far, there have been a number of unexpected highs and a number of unexpected lows. The primary care physicians of RGVHA hope that by sharing their story, they can help you better navigate your own ACO course.

Opportunity for primary care

Dr. Luis Delgado became intrigued by the possibility under accountable care of rewarding primary care physicians for the savings they generate while maintaining or improving quality. Instead of resisting change, he saw opportunity.

He also saw a chance to do something about McAllen’s reputation, gained through Dr. Atul Gawande’s 2009 article in the New Yorker entitled, "The Cost Conundrum." That article focused on McAllen’s Medicare health costs, which were almost twice those of its Rio Grande River neighbor, El Paso.

However, beyond having a vision, he had no know-how and no budget.

Fortunately, as readers of this column know, there is so much documented "low-hanging fruit" for primary care to generate savings through value-based care that the strategic time and expertise expenditures proved not to be significant. The legal structure and backroom business logistics for a small network-model primary care physician ACO are also relatively straightforward. RGVHA has two full-time administrative staffers, one part-time president (Dr. Delgado), and one part-time medical director (Dr. Roger Heredia).

However, the new ACO data collection, sorting, and reporting requirements were somewhat daunting – that is, until they met Dr. Gretchen Hoyle of MD Online Solutions (MDOS). Dr. Hoyle is a practicing pediatrician who spearheaded the design of a physician-friendly care management data system for her practice and found it ideal for the accountable care era. Her company targets small- to medium-sized physician-led ACOs.

MDOS was able to tailor a nimble ACO solution scaled to RGVHA’s needs, thus allowing RGVHA to supply its last missing piece in a cost-effective manner. Because she is a practicing physician, Dr. Hoyle helps interpret the data and leads a weekly data-driven staff conference call with the ACO’s nurse care coordinators.

Approved for the Medicare ACO

Despite initial fears, RGVHA found that the MSSP application process was not intimidating at all. It turned out to be a reflection of its business structure and primary care physician ACO strategy.

"If you get your game plan together ahead of time, independent primary care physicians should be successful in applying for the Medicare Shared Savings Program," stated Dr. Delgado. "We found that Medicare is supportive of this type of ACO, I guess because it sees their potential to improve health care," he said.

The Centers for Medicare & Medicaid Services does indeed support these types of ACOs, as RGVHA qualified for one of the last Advanced Payment Program grants. The CMS is so confident that these physician-led, nonmetropolitan ACOs will work, that the agency actually fronted the infrastructure and operational money to them. RGVHA was one of the last grantees of this one-time appropriation.

They began the MSSP program Jan. 1, 2013, opting not to take risk and to receive 50% of the savings they generated for the 5,000 patients attributed to them, if quality and patient satisfaction metrics are met.

‘I haven’t had this much fun practicing medicine in 10 years!’

To decide what type of initiatives to undertake, the physicians read the Physician’s Accountable Care Toolkit (profiled in an earlier column) and convened a weekend workshop. They were pleasantly surprised when they realized that so many savings and quality improvement opportunities are available to primary care physicians under accountable care – and control over the physician-patient relationship was being returned to them.

They targeted diabetes management, patient engagement, best practices for enhanced prevention and wellness, and home health management.

One physician summed up the mood when she exclaimed, "I haven’t had this much fun practicing medicine in 10 years."

As they celebrate their first year under the MSSP, how are they doing? Check in next month for part 2: Our secret weapon, and our biggest disappointment.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians in forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or at 919-821-6612.