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    Defining what makes a successful accountable care organization (ACO) can be looked at in a few different ways.

    At its most basic, it’s “trying to get physicians who are not on the same tax ID number to be able to move in the same direction,” according to Lawrence Preston, MBA, FHFMA, chief executive officer and cofounder, Silver State ACO, who joined Rhonda Hamilton, LPN, chief operating officer, Silver State ACO, in talking about Silver State’s journey at the 2021 Medical Practice Excellence: Leaders Conference.

    It’s much more complex than that, of course: The challenge of this approach is successfully using analytics to influence physician behaviors and staff workflows to better coordinate care, control costs and effectively manage specific quality improvement plans.

    “The most difficult thing is the coordination of care,” Preston said, in starting out as an ACO, since there’s generally no good sense of what beneficiary spending is. That information is even harder to get in areas where the beneficiaries are “snowbirds” and travel throughout the year and get care across the country.

    Background and results

    Silver State ACO got started in the Medicare Shared Savings Program (MSSP) after applying in 2013 and starting in 2014 — opting to operate as a Track 3/Enhanced ACO in Nevada to equally share generated savings with the government — and serving an area with 45,000 attributed beneficiaries across more than 730 participating providers with 55 independent tax ID numbers and more than 20 unique EHR and practice management (PM) systems among them.

    In some ways, Silver State is “very disjointed” because of that variety and because some of the participating providers traditionally competed against one another. The ACO helps unify them under the same goal, Preston noted, by helping them utilize information they didn’t have before about those patients and the costs of care delivery.

    Under the plurality model of patient attribution, providers with the most visits and E/M codes generally get patients attributed to them. In Silver State’s area, about half of a primary care physicians’ patients are attributed to the PCP, and the rest to specialists. “That’s a bell curve we would love to be able to flatten out,” Preston said, noting that the PCP’s role in care coordination would ideally lead to most of those patients being attributed to a PCP. “We would love to see a 75-25 [split].”

    From 2015 to 2020, the ACO achieved shared savings six times and generated more than $162.8 million in savings to the Centers for Medicare & Medicaid Services (CMS), which was good enough to rank in the top 6% of ACOs in 2020, including ranking eighth out of the top 10 ACOs in the United States in earned savings and second overall for per beneficiary savings.

    Tactics for success

    With an ACO constituted of independent practices and no employed physicians, the main challenge was to impress upon physicians the benefit of joining the ACO. In this case, it was the dual improvement of quality and revenue.

    Hamilton said the challenge for many ACOs is finding the right combination of quality improvements to reap the increased revenue from shared savings — a path typically involving successful annual wellness visits (AWVs), chronic care management (CCM) and transitional care management (TCM).


    Silver State ACO produces a list to participating providers of which of their ACO-attributed patients are eligible for an AWV.

    If visits are coded and billed properly, Hamilton said, each AWV could generate up to $288 in 2021 (based on the Nevada non-facility rates) while closing care gaps and improving quality scores for value-based programs (e.g., MIPS):

    • Subsequent AWV (G0439): $135.57
    • Annual alcohol screen (G0442): $19
    • Annual depression screen (G0444): $19
    • Annual advance care planning (99497): $87.32
    • Annual cardiovascular disease counseling (G0446): $27.44


    The ACO also provides a list to each participant showing them which ACO-attributed patients are eligible for CCM. Medicare will reimburse for 20 minutes of non-face-to-face time spent coordinating care for patients with multiple chronic conditions.
    In the realm of CCM, there’s $41.77 per patient for each 20-minute visit (code 99490). Other revenue opportunities for CCM include:

    • 99491 (practitioner only, 30 minutes); $83.70
    • 99487 (complex, first 60 minutes): $92.56
    • 99489 (complex, additional 30 minutes): $44.54

    “We really stressed this program,” Hamilton said, as it benefits patients and is very effective in controlling costs. “We’ve seen that our ACO program can help reduce unplanned admissions as well as lower readmit rates,” she added.

    Hamilton noted there are several vendors that can assist with CCM and cautioned to find a very experienced organization that understands the specific requirements so that your work stands up to a Medicare program audit. “One of the questions you should ask during your RFP process when you’re vetting out vendors [is] if they’re going to support you through any Medicare audit,” Hamilton said.


    Hamilton noted that the Medicare program pays well for TCM services because the federal government “really does see the value in having a patient seen in your practice after they’re discharged from an inpatient hospital setting,” she said, for its ability to reduce readmit rates.

    Silver State ACO has a system for practices to receive real-time notifications when a patient is seen in the hospital or emergency department (ED), as well as real-time notifications for patient discharge, Hamilton said, which lays the foundation for reaching out to those patients to schedule TCM.

    This area of the Medicare program also has very specific guidelines, especially for documentation, Hamilton advised. TCM for Silver State ACO pays $285.07 if seen within seven days, and then $210.53 if seen within 14 days. Adjusting for complexity, code 99495 (moderate complexity) yielded $210.53, whereas 99496 (high complexity) yielded $285.07.

    Tools for ACO success

    All this work flows from physician behavior to engage with patients to close care gaps and succeed in these specific programs. To do this, Silver State ACO uses several tools:

    Quality coordinator recaps

    Silver State ACO uses this internal tool to measure how many staff are needed for chart reviews and face-to-face meetings related to quality work. This analysis helped the ACO find that about 4,500 attributed lives per quality coordinator provided time for chart reviews, meetings and ongoing education in support of the quality programs, Hamilton said.

    “Education on the quality measures isn’t something that can just be done once,” she said, especially considering the rates of staff turnover that necessitate education for new hires. “It’s done on an ongoing basis,” which also helps provide reminders for those who might lose sight of the quality goals over time.
    Silver State also works to ensure practices have their ACO signage in the lobby, along with required Medicare signage.


    With all this data coming to the ACO, Silver State then provides practice-level and provider-level scorecards with feedback on spending, quality metrics and utilization for attributed patients. As Hamilton outlined, the first part of the scorecard covers spending, including year-to-date (YTD) average per-patient spend, YTD benchmark goals and the difference between the two. The latter part of the scorecard focuses on utilization metrics compared to Medicare fee-for-service (FFS) benchmarks.

    The ACO also breaks down quality measure scores for practices based on specific items found in patients’ charts (e.g., screening for fall risk, influenza immunization, cancer screenings), comparing the practices’ YTD scores against past-year ACO scores and CMS 90th-percentile benchmarks. “We expect these scores to be lower in the beginning of the year and expect them to increase as patients are seen and care gaps are closed,” Hamilton said.

    Risk stratification

    The ACO pays close attention to attributed patients’ Hierarchical Condition Category (HCC) codes. Since scores reset year to year for patients, Silver State will watch for HCC codes not billed in the current year compared to a past year so there are not lost opportunities for accurate risk stratification of a patient. This includes diagnosis and medication codes that have been added or removed from the previous year, so a provider can see if something needs to be addressed.

    Given the variety of EHRs and PM systems used across the ACO, Hamilton also cautioned to look at EHR billing systems and ensure they do not limit the number of codes a provider can add.

    Expenditure and utilization reports

    Using data from CMS, the expenditure and utilization reports offer data at the levels of Taxpayer Identification Number (TIN), division, provider and patient to identify areas of opportunity for improvement on spending, compared to the ACO’s overall score and national FFS averages.

    Hamilton noted this is especially helpful to identify patients with the highest number of claims and most costly patients, allowing quality coordinators to flag them for the practice to address. In one case, the ACO found a patient was being seen in the ED as often as two times a week over several months on account of not being able to get an appointment with their provider. “That provider made sure that patient got on his schedule,” Hamilton noted. “It’s certainly more cost effective for the patient to be seen in the office on a weekly basis rather than seen in the ED even once a month.”

    Practice recaps

    Monthly practice recaps are checklists for quality coordinators to review when they meet with each practice to ensure AWVs, CCM and TCM work is on track, whether done in-house or by a vendor. Silver State ACO also keeps a close eye on whether the practice is logging into the ACO’s online tools, such as an analytics portal and the admit/discharge notification system.

    This recap also tracks providers who have left or joined to make notes about educating new providers on ACO goals, as well as any new or closed locations and any changes to the practices’ TINs.

    This culminates with an in-depth care gap discussion each month, tailored to each provider, based on trends identified in monthly chart audits and report reviews. This is an opportunity to make suggestions to the practices about changing workflows, EHR templates or documentation to ensure they are meeting Medicare program requirements.

    “These reports took us six, seven years” to create, Preston noted. “And we keep refining them. … We can’t stay static.” By routinely addressing these items with providers and back-office staff at the practices, it gives the entire organization an understanding of their involvement in the ACO.

    Lessons learned

    From 2014 to 2021, Silver State ACO grew the number of participant groups from 20 to 55 and the number of attributed lives from 12,198 to approximately 45,000, Preston noted. Adding new practices to the ACO sometimes resulted in quality scores taking an initial hit, as they were new and not accustomed to the best practices needed and support offered from the ACO.

    Through this careful series of actions to monitor performance, promote best practices and generate savings, Silver State ACO improved its overall quality score each year, from 87.47% in 2015 to 98.75% in 2020. This included a substantial increase in AWV completion rates, from 8.6% in 2015 to 32.97% in 2020, and a sizable increase in CCM enrollment, which grew 41% from 2015 to 2020. Preston also shared that the ACO increased completion of TCM visits 50% from 2015 to 2020.

    “All three of these programs are directly reimbursable to the physician … [and] they directly impact what’s going to happen overall to the ACO,” Preston added.

    Hamilton stressed the importance of keeping practice office staff informed of these efforts in addition to physicians. “A lot of times it’s the [medical assistant], the practice manager, the dedicated quality person that can be the catalyst for needed change,” she said.

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