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How an accountable care organization in one of the nation’s poorest regions is improving diabetes care for its patients on a pay-for-performance model.
In October 2013, the Los Angeles Times reported that the Rio Grande Valley in Texas has two of the three poorest metropolitan areas in the nation. A month later, the Texas Medical Observer announced the release of a documentary called “Diabetesville USA,” filmed in Cameron and Hidalgo counties, in the Rio Grande Valley, where it is estimated that more than 29% of the population lives with Diabetes Mellitus (DM). Poverty and disease are intimately connected.
The Rio Grande Valley ACO (RGV ACO)is one of the first Medicare ACOs in the country. We serve the communities in Hidalgo and Cameron counties and have a first-hand view of the problem.
RGV ACO adopted the Center for Medicare and Medicaid Services (CMS) vision of better care for individuals, better health for the population, and slower growth in Medicare expenditures, and since our inception in 2012 we have been committed to being part of the solution. Studies show that improving the quality of healthcare delivered to patient’s leads to decreases in the costs of care.
As a participant in the Medicare Share Savings Program (MSSP) with a dual-eligible Medicare-Medicaid patient population penetration of 40%, RGV ACO is in a unique position to reduce the human and healthcare costs associated with DM and other chronic diseases.
DM is one of the most dangerous chronic diseases of our time. Forty-two percent of RGV ACO’s Medicare beneficiaries live with this disease.
The stakes are high in terms of both comorbidities and mortality. DM is one of the leading causes of blindness, end-stage renal disease (ESRD) and cardiovascular disease. Renal failure occurs more often when uncontrolled DM is combined with uncontrolled hypertension.
The incidence of atherosclerosis increases significantly when dyslipidemia, tobacco smoking and hypertension are added to the equation, resulting in a high incidence of coronary artery disease, stroke and peripheral vascular disease. These can, in turn, lead to costly interventions, such as stenting of coronary arteries, bypass surgery and lower-extremity amputations.
A multidimensional approach to diabetes care that emphasizes blood pressure, lipids, glucose, aspirin use and tobacco avoidance maximizes health outcomes more than a strategy limited to one or two of those clinical domains. Indeed, the CMS grouped these five domains in the MSSP final rule, which defines the DM composite measures with which ACOs must be compliant.
It is an “All-or-Nothing” method of scoring: If a patient fails to be compliant with one quality measure (QM), the ACO is deemed to have failed in all five measures for that patient.
In 2012, RGV ACO’s first year, we were achieving 70% to 80% patient compliance on individual’s DM quality measures. However, controlling at goal all measures combined on every patient across our entire diabetic population turned out to be difficult, and our compliance rate was 23%, similar to the national average. Therein lay the challenge.
Next: The solution and results
Improving the quality of care for our patients and improving our “quality scores” became our motivating factors.
To meet the challenge, we deployed a full care coordination model and initiated a strong team-based, patient-centered care approach. We created a diabetes education center, where a DM educator trained a team of medical assistants and licensed vocational nurses. They were also trained as care coordinators, and at least one was added to each clinic.
In some clinics, health coaches joined the team and we established a call center targeting uncontrolled DM patients. We made routine calls to survey blood sugar levels, and remind patients to take their cholesterol and blood pressure medications. Self-management education was in full force.
We optimized the use of our electronic health records (EHR) system to enable the team to use pop-up reminders to track each patient’s HbA1c, low-density lipoprotein cholesterol, blood pressure, smoking status and the use of anti-platelet therapy.
Everyone on the team clearly understood that it was unacceptable for a patient with poorly managed HbA1c, blood pressure and high cholesterol to leave the office without addressing the problems and adjusting the medications. We impressed upon the providers the need to take extra time to figure out what patients require.
As a result, our compliance rate began to shift upward. The 2013 QM samples we submitted to CMS demonstrate that an encouraging 75% to 90% of patients are at goal on individual DM QMs, and 48% of patients are compliant with all DM clinical measures at once (“all-or-nothing” scoring). We achieved a better than 100% improvement on the combined measures in one year, which places us in a very high percentile.
Uncontrolled DM and its comorbidities lead to staggering economic challenges for insurance companies and taxpayers.
These include more frequent hospitalizations (at an average cost of more than $17,000 per episode), more expensive laser treatment for DM retinopathy, coronary artery bypass surgery (at around $50,000 to $60,000 per episode) and other expensive procedures. A patient with DM and ESRD costs Medicare an annual average of $75,000.
By implementing aggressive primary and secondary prevention, in a patient–centered environment, with EHR optimization, focus on high-risk patients and adding a care coordinator to each office, RGV ACO has saved Medicare several million dollars.
If the various care coordination and quality improvement programs followed by many ACOs and other programs across the country become more widely adopted, the potential for Medicare and healthcare providers to improve the care of our patients and save billions of dollars is within reach.
With patients and physician’s engagement, access to cost of care data and a focused leadership team, it can be done.
Jose F. Pena, MD, is the chief executive officer and chief medical director for the Rio Grande Valley Accountable Care Organization in Rio Grande Valley, Texas.