ACOs: What the Henry Ford Physician Network Can Teach - Insight Driven Health
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Insight Driven Health ACOs: What the Henry Ford Physician Network Can Teach
Copyright 2011 Henry Ford Health System
Accountable care organizations Dr. John Popovich recalls many
meetings in which physicians would
However, half a year after the launch
of the Henry Ford Physician Network
Recruitment of independent care
providers is by no means HFPN’s only
Although still in its early days, the
HFPN offers valuable insights into the
(ACOs) are one of the most promising sit with arms crossed, telling him
and his team why the accountable
(HFPN), today’s discussions are very
different. “Now they’re about how we
success to date. The network presented to
the U.S. Federal Trade Commission (FTC),
practicalities of developing and operating
an ACO. This paper takes a look inside
responses to healthcare reform. One of
care organization (ACO) model they do this together,” says Popovich, the which has indicated that the program the network, explores the rationale for
were planning would never work. organization’s chief executive. That goes is very innovative. The FTC has made forming it, and shares some of its best
for doctors from independent practices it clear that it does not stand in the lessons to date.
the best examples to date is the Henry Although the skeptics weren’t averse to
the principle of a coordinated system of in the network’s region of southeast way of innovation. Also, the HFPN has
Michigan as well as physicians in the cataloged and selected key performance
Ford Physician Network in Michigan. care delivery that would align physicians,
hospitals and ancillary services around Henry Ford Medical Group, part of the metrics for each clinical specialty. It has
ACO’s parent organization. Already, done a superb job of communicating
Here’s how much the new group has initiatives for clinical integration and
quality improvement, they were not the new ACO has signed up over 200 its objectives, plans and advantages. Its
independent practitioners—including nuanced governance systems ensure
achieved already—and a sense of how convinced that it could function without
hurting their interests. some who once sat with arms folded. balanced representation among employed
One recent big win: Infinity Primary and independent physicians, and among
far it has to go. Care, a group of 52 family and internal
medicine physicians, which signed on in
primary care physicians and specialists.
Physicians inside and outside the Henry
January 2011. Ford system are excited and engaged. And
the organization is starting to create a
shared culture centered on quality of care
and cost-effective care.
“Development of an ACO provides the
opportunity to transform care delivery.”
The promise of ACOs
ACOs are shaping up to be one of quality and costs and for coordination of lower costs and better patient outcomes.
the best ways to realize the promise care. It must have a discrete management It can help augment accountability
of healthcare reform. They align and leadership structure for decision- and transparency on quality and cost
physicians and hospitals to collaborate making. There should be a formal legal issues. An ACO can be a good vehicle for
in coordinating care to improve quality structure that allows the organization coordinating care across the continuum
and reduce costs. In a recent survey, to receive and distribute bonuses to of healthcare. And it can provide an
70 percent of hospital leaders thought participating providers. effective channel for measuring quality
their institution would be part of of care, managing payments, and more.
The U.S. Department of Health and
an ACO inside five years.1 Whether And, by virtue of joint contracting and
Human Services’ Centers for Medicare
formally initiating an ACO or not, sharing of cost savings, an ACO can help
and Medicaid Services (CMS) will require
health systems increasingly see that to strengthen a hospital’s alignment with
that an ACO includes primary care
continued pressure on reimbursement, independent physicians without having to
physician (PCP) capacity for at least
coupled with rising labor, supply and employ them.
5,000 Medicare beneficiaries. The ACO
pharmaceutical expenses make it
must be able to provide CMS with a list Although several different organizations
imperative to push for greater cost-
of participating PCPs and specialists, can form an ACO, to date most activity
effectiveness while improving the
have valid contracts with a core group has been among hospital systems seeking
quality of care. Put simply, ACOs are
of specialists, and be able to participate to form ACOs and payers seeking to
a good way for providers to deliver
for a minimum of three years. Most redefine their roles in providing ACO
more value to patients and payers.2 healthcare systems have some but not all support services. Health systems have
To be properly recognized as an ACO (it’s of the necessary capabilities to function been able to make decisions quickly and
easy to claim to be one, and difficult as an ACO. have the funds and resources to build the
to disprove clever marketing to that Development of an ACO provides the infrastructure needed for development of 1
Shortell SM. Accountable Care Organizations. In: The Society for Healthcare
effect), an organization must be able opportunity to transform care delivery physician-led ACOs. Strategy and Market Development (editor). Futurescan 2010: health care trends and
implications 2010-2015. Chicago, IL
to demonstrate a range of well-defined in several ways. It can provide greater
characteristics. To begin with, it must have support for evidence-based medicine
2
MedPAC has defined Accountable Care Organizations (ACOs) as a set of providers
associated with a defined population of patients, accountable for the quality and
defined processes for reporting on care that helps reduce variability, leading to Copyright 2011 Henry Ford Health System cost of care delivered to that population.
“Clinically integrated physician networks “The HFPN is truly “physician-led”;
create strong interdependence and physicians will comprise more than
cooperation between private practice 80 percent of the voting members
and health-system employed groups.” of the board.”
A foundation in clinical integration A look inside the HFPN
HFPN exemplifies the clinical integration centered tools and approaches that Set up in June 2010, HFPN it is a “Henry Ford Medical Group was looking (HIE). “The quality-of care metrics are independent and owned physician groups
model, where physicians collaborate in include the use of advanced information separate legal entity and wholly owned for ways to partner with the System’s being developed by subsets of the who admit to those facilities. That
a defined network to improve quality technology to support communication subsidiary of Henry Ford Health System. voluntary staff,” says Mark Kelley, M.D., community physicians as well as our geographic dispersion made it all the
and efficiency. Says Dr. Jerome Finkel, between the doctor, his or her colleagues The Henry Ford Health System includes CEO of Henry Ford Medical Group and Henry Ford Medical Group physicians,” more important to standardize care based
president of Internal Medicine Associates and patients. It also allows physicians to the 1,100-physician Henry Ford Medical chief medical officer of the Henry Ford says Henry Ford Medical Group CEO on leading practice, use technology to
of Mount Clemens and one of the first demonstrate their quality and efficiency Group—which played a major role in Health System. “That way, we’d be able Kelley. “They’re mostly physician-specific share clinical data, improve coordination
independent physicians to sign up with to current and future patients, payers
planning and supporting the HFPN’s to amplify the quality of the system and metrics, not hospital-specific metrics.” and continuity of care delivery, and
HFPN: “We recognize that patients, and employers, and to enter into “pay-
development—along with the academic also attract more patients who could So HFPN’s core tenets include enhanced establish uniform expectations, metrics,
insurers and employers in our region are for-performance” and other contractual
looking for physicians to lead the way in arrangements with health plans in ways Henry Ford Hospital, four community see that all the doctors were aligned accountability, dissemination of best targets and thresholds—in short, to
improving healthcare. Clinical integration that financially recognize the physicians’ hospitals, a health plan (HAP, the Health and coordinated, whether in the group practices, provision of practice support have agreed-upon ways to measure
is a proven model for doing that.” efforts to improve quality and efficiency. Alliance Plan), and behavior health and practice or in Independent practice.” and tools, improved care coordination, and performance that would work across the
community care services. The physicians provision of tools for patient engagement. Henry Ford Health System.
Clinically integrated physician networks Clinical integration can benefit hospital HFPN includes significant representation
of the Henry Ford Medical Group initially
create strong interdependence and systems too. In addition to providing and participation by private practice and Four factors were especially relevant At the same time, large Michigan auto
cooperation between private practice a framework for joint contracting and accounted for 80 percent of all those
hospital-employed physicians. Crucially, to HFPN’s formation. To begin with, industry employers were anxious to see
and health-system employed groups; sharing of cost savings, it can help in HFPN; that figure is expected to
HFPN physicians are able to retain their healthcare reform meant that payment higher quality of care for their workers
they are well-placed to control costs them to develop more collaborative decline over time as more independent
current practice structures and business systems would change. And complex new at lower cost. Specifically, there were
and ensure quality, and to demonstrate relationships with their medical staff, physicians join the clinically integrated
models. The central idea for the network regulations, coming from the American requests for a major e-prescribing
value to payers and employers through enlist physician support for quality model of care.
is to leverage the Henry Ford Medical Recovery and Reinvestment Act (ARRA) initiative to cut prescription costs and
physician-driven quality initiatives. initiatives, and position themselves
HFPN is designed to implement its Group experience and infrastructure in and Meaningful Use requirements in improve quality, and a subsequent
Clinical integration can remove barriers well on the basis of quality and cost-
clinical integration strategy through quality improvement to create a vehicle particular, required appropriate and request for access to a high-performance
to the coordination of patient care across effectiveness. And for employers,
providers and settings to help achieve integration can give them the means to four regional care collaboratives (RCCs) for tracking performance with metrics insightful responses. physician network to improve the
care that is safe, timely and effective. better manage the healthcare costs of loosely aligned to four geographic selected by the physicians themselves, health of employees and reduce overall
Furthermore, the fact that the Henry
employees and their dependents through regions in southeast Michigan. The to extend the use of technology into healthcare costs.
Specifically, clinical integration seeks to Ford Health System is comprised of
the purchase of better, more efficient HFPN is truly “physician-led”; physicians independent practices, and to share
provide patients with consistent high- geographically dispersed community
health services. will comprise more than 80 percent clinical information across the network
quality care from trusted sources—their hospitals required the development
own physicians—through patient- of the voting members of the board. through a Health Information Exchange of a deliberate strategy to engage
“In signing the HFPN participation
agreement, physicians commit to
the goals of clinical integration,
adoption and adherence to
physician-developed standards to
improve quality and efficiency.”
Benefits for and requirements of physicians Copyright 2011 Henry Ford Health System
Participation in the HFPN is open to all There are many attractions for physicians In signing the HFPN participation With help from Accenture’s consulting And if doctors don’t perform to HFPN
medical staff with current privileges in southeast Michigan. They get the agreement, physicians commit to the services throughout the assessment, standards? There are plans for that. The
at Henry Ford Health System (HFHS) chance to be part of an innovative goals of clinical integration, adoption design and implementation phases performance of individual members will
hospitals. Those heading up physician physician-led organization committed to and adherence to physician-developed of the ACO effort, the network has be reviewed at the physician level and
enrollment have been careful to recruit demonstrating measurable improvements standards to improve quality and developed detailed procedures for in aggregate across the HFPN by the
strategically—for example, appealing to in the quality of health care and in efficiency. They agree to be measured onboarding, orientation and training to regional care collaborative (RCC) medical
the early adopters and targeting naysayers expanding that impact in the state. and to share clinical data and other help doctors transition to the network. directors. Physicians who don’t meet
whom they believe will become some While maintaining their practices’ current information that facilitates measurement. As they join, the physicians are contacted the mark will be flagged with an action
of the strongest advocates if they join. business models, they gain enhanced They also commit to collaborate—probably individually to schedule orientation plan developed in collaboration with the
Notes Dr. Charles Kelly, the chief medical access to the Henry Ford Medical at levels of intensity beyond what many sessions to help them prepare to physician’s designated group leadership,
officer of HFPN: “One of the continual Group’s clinical research and to HFHS’s of them have experienced—with HFPN meet the requirements of the clinical using a consistent network-wide timeline.
hurdles [in recruiting physicians] is resources and services. Participation participants to improve performance program, technology requirements The RCC medical directors are responsible
that the network is not trustworthy.” in the network includes access to and to adopt technology offered or and implementation schedule. for reviewing individual performance,
affordable technology solutions that recommended by the HFPN (including collaborating with designated group
can help physicians make their practices high speed Internet access, e-prescribing, leadership to review performance,
more efficient and help them work a disease registry, and data exchange discuss action plans, confirm target
toward Meaningful Use requirements. tools). Participants also concur that resolution periods, define potential
they are willing and ready to maintain consequences, and notify the provider
their medical staff membership in network committee of issues or concerns.
good standing at an HFHS hospital or
maintain their credentials according to
HFHS-affiliated hospital standards.Cornerstones for ACO success
So in the months since HFPN started up, what do its
experiences tell us about the factors that favor success
for ACOs?
These lessons stand out:
Collaboration is king. Top management is wholly committed—and engaged. Relevant metrics are key. Good governance goes deep.
Although the Henry Ford Health Since ACOs and clinical integration Commitment must, of course, be Physician performance will be measured The HFPN is governed by a 16-member On the ground, each regional care
System provides firm foundations, the are nothing short of a mission change matched by action; although physician initially using a defined set of 104 board of trustees with equal collaborative is led by a regional medical
Network’s design, development and for many organizations, and many leadership is key, aggressive program measures, developed by a cross-section of representation between independent director who organizes activities within
operation are absolutely dependent stakeholders won’t easily share the and project management is what makes physician members and ensuring at least and owned physician groups. Physician the program to enable compliance
on the enthusiastic involvement of vision (especially those expecting things happen at HFPN from day to day. five meaningful specialty-specific metrics members of the board represent primary with the intent and requirements
physicians—those employed by the Henry to be adversely impacted by volume The network now has a chief medical for the first year. Quality measures will be care and specialty fields, as well as each for clinical integration. For instance,
Ford system as well as by independent drops or aggressive pricing moves), officer—Dr. Charles Kelly, formerly applied to every physician in the network. of the four geographic regions that the director will track and evaluate
physicians across southeast Michigan. a strong management team must be Chief Medical Officer of Henry Ford (All quality improvement efforts will be comprise the network. Oversight and physician performance in the region,
CEO Dr. John Popovich notes that at the helm—backed by a detailed Macomb Hospital—whose job it is to managed by the network’s physician guidance in development of programs recommend inclusion or exclusion of
collaboration produces its own virtuous business case and plan for managing lead development and implementation of participants.) Quality measures and is the job of three board committees— physicians in the network, represent
circle. “As physicians [from different the interests of all stakeholders. ACO’s clinical performance improvement benchmarking targets will be used to set the clinical integration committee and RCC physicians on the HFPN board of
fields and practices] work together, efforts and administration of regional performance expectations for clinicians. informatics work group, the provider trustees, and work to build alliances
HFPN benefits from the wholehearted,
they find more shared values,” he says. care collaboratives. And in Matthew Individual and group physician scorecards network committee, and the finance with regional hospitals to align efforts
unwavering commitment of a large team
He sees it in the way in which HFPN Walsh there is a dedicated vice-president will be published quarterly using Crimson committee and payer relations work toward achievement of HFPN goals.
of the most senior Henry Ford executives,
doctors are starting to refer patients of operations who is in charge of technology, with metric performance group. Again, each committee comprises
from Popovich—also the CEO of Henry HFPN physicians meet in clinical
to each other—and in the inclusive developing the network of physicians. and applicability reviewed (and revised balanced representation of independent
Ford Hospital—to Bob Riney, COO of management forums to discuss care
language that they now use. “There’s if needed) at least annually by the and system physicians, as well as among
the Henry Ford Health System. “The quality, efficiency and costs. The
a real change in culture,” he says. membership. Performance expectations primary care physicians and specialists.
first major success is that we made a collaborations involve dialogues
commitment to do this,” says Riney. “We will be linked to reward structures that
with other HFPN physicians in a
have been yearning for the right vehicle are consistent with negotiated contracts.
particular region, specialty, or other
to give us the opportunity to drive natural alignment, with the goals
something like this.” of promoting and disseminating
best practices to HFPN members,
providing appropriate case reviews
of clinical outliers, and implementing
utilization management programs.IT really matters. Copyright 2011 Henry Ford Health System
One of the foundational elements of The connectivity solutions feature four Other foundation components include The HFPN recognizes that physicians
the ACO is that all participants have categories of base components and help secure messaging to provide online are at various stages of adopting the
access to, and make use of, leading participants to work toward Meaningful communications between patients, the technologies that will give them access to
information technology tools for the job. Use. There is a disease registry—a solution Henry Ford Physician Network, and Henry the clinical information they need to deliver
(The availability of better IT offerings for helping providers treat chronic Ford Health System-affiliated physician the highest quality care at the lowest
contributes to the perception of why diseases and conditions using tools that community and their office staff, together cost. So the network will offer a number
things are different now than they were manage observational, epidemiologic, and with reporting that meets HFPN’s of technology solutions to both HFPN
in the managed care days.) All technology other data at the point of care. There is regulatory requirements. members and other physician members of
solutions for Network participants also a health information exchange (HIE) the community, with a differential discount
include interconnectivity, as well as —a secure platform that accommodates offered to members of the HFPN. Base
connectivity to all Henry Ford Health the sharing of results and clinical data components of these clinical solutions
System hospitals in order to facilitate between the Henry Ford Health System include an electronic medical record,
sharing of important clinical patient data. hospitals, Henry Ford Physician Network, electronic health record, patient registry,
and Henry Ford Health System-affiliated HIE, secure messaging, e-prescribing,
providers and patients. practice management, and more.“The ACO has attained impressive
momentum in a very short time. It has
the strong support of regional employer
groups, and it has built the kind of
collaborative framework whose full
potential can only be glimpsed.”
The Willingness of Payers to Reward the Value
For all of its successes to date, But its biggest hurdle will be the Kelly and his fellow executives are in
HFPN faces plenty more challenges. willingness of payers to reward the value talks about contracts with a variety of
To begin with, it must continue created by HFPN’s clinical integration. payers—including the Henry Ford Health
the not inconsiderable effort of With real money on the table, HFPN’s System’s own insurance company, Health
identifying, wooing and enrolling collaborative bonds will be tested, as will Alliance Plan, which covers the system’s
independent physicians. According the model of aligned financial incentives. 40,000-plus employees—and they expect
to HFPN, it must extend the dialog The metrics it has so meticulously to have a signed contract in hand soon.
with payers and employers. It developed will be proved to be the Until then, one proposed response may be
has to be able to demonstrate its right metrics—or not. And it remains to use technology to simulate operations,
credentials to distinguish itself from to be seen whether the governance incentives, and perhaps even behaviors
all those that claim to be ACOs. systems that the teams have so carefully for different sizes and types of contracts.
constructed can really be effective when
So far, so good for the Henry Ford
participants see the financial prize in
Physician Network. The ACO has
front of them. Already the lack of a
attained impressive momentum in
contract is something of an impediment
a very short time. It has the strong
to attracting physicians. “A contract is
support of regional employer groups,
definitely a reason to join the ACO,” says and it has built the kind of collaborative
HFPN medical chief Kelly. “It’s a barrier
framework whose full potential can only
not being able to articulate [our story] to
be glimpsed. With the striking successes
a broader group that are interested in the
it has achieved to date, there is every
financial detail.”
likelihood that HFPN will continue to
blaze trails that make a difference for
patients and payers alike.Contact Accenture: Insight Driven Health NOTE: Though Accenture has resources
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