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Orgo-Life the new way to the future Advertising by AdpathwayThe National Association of Accountable Care Organizations (NAACOS) recognized three ACOs with awards at its fall meeting last week. During an Oct. 16 panel session, representatives from the award winners, Bryan Health Connect ACO in Nebraska, Ochsner Accountable Care Network in Louisiana, and TriValley Primary Care in Pennsylvania, discussed some of their accomplishments and lessons learned in accountable care across different lines of business and payers.
In its award presentation NAACOS described Bryan Health Connect ACO as having built a scalable, technology-enabled infrastructure that integrates real-time data, care coordination, and partner engagement across its value-based care network in Nebraska. By leveraging advanced analytics, automated patient transition alerts, and strong collaboration with post-acute providers, the organization has achieved sustained improvements in quality, utilization, and total cost of care.
Jessica Heckman, M.D. vice president of medical affairs, said Bryan has about 2,000 providers in its ACO across the state of Nebraska. Among their quality initiatives was a focus on the three-day waiver rule, which they started in late 2023, and saw a really good uptake over the course of two years. “We reduced our SNF spend by $4.7 million while also reducing our inpatient length of stay and our SNF length of stay,” Heckman said. “We did this through a few different measures and really engaging with our SNF partners. Our care navigators have been really helpful in that regard.”
Despite seeing rapid growth of the ACO, Bryan has managed to create an upward trend with regard to its blood pressure control and a decrease in glycemic out of control range by 11.8 percent over this time frame through several of its quality initiatives.
They also saw improvement in their 30-day readmissions rates, decreasing it by 60% over the course of two years. ”Our care navigators were really integral in this, focusing on making sure we have immediate reach-out touch points, particularly for our high acuity, high-need patients. That’s been a big help in terms of our data overall,” Heckman said. “We have used Bamboo Health for this. It lets us know when our patients are being admitted immediately, when they're transitioning to a SNF, or when they are returning home….That’s so much more helpful than finding out two weeks after the fact, especially when we work in an ACO that has 35 different EHRs in it, so we don't have a singular one that we can utilize.”
Heckman said she appreciates the engagement not only of the Bryan team but of the physician members in our ACO to focus on “what can we do to be doing the right thing at the right time for the right patient.”
In its award presentation, NAACOS noted that Ochsner Accountable Care Network (OACN) serves more than 60,000 Medicare beneficiaries and more than 535,000 patient lives across all lines of business through more than 3,500 clinicians. Their population health model operates in Louisiana, Mississippi, Alabama, Florida, Georgia, and South Carolina to integrate clinical care teams, post-acute providers, and community organizations around patient needs. Ochsner leverages advanced technology, coordinated care management, and community partnerships to improve preventive care, chronic disease outcomes, and patient experience while reducing costs across government and commercial contracts.
Beau Raymond, M.D., chief medical officer for population health at Ochsner, said the organization has two ACOs: The OACN is in the enhanced track of MSSP; the other is called the Ochsner Senior Care Network, which is in Track A and is considered as sort of an ACO with training wheels. “It’s where we have people who are new or people who weren't doing well beforehand. We place them into that ACO, work with them, help develop them, and then move them into the enhanced track as they get better,” he explained.
Ochsner has a dedicated team that reviews health system data to find where there are opportunities for improvement on things such as risk adjustment, pharmacy spending or care spending. “We'll review that information and decide whether it's something we can actually act upon. It may be nice, but if you can't develop a program around it or do something differently, then there's not much we can do with it,” Raymond added. “We have to figure out whether we can act upon it.” After making a change, such as something built into Epic, they look to see if that worked, and go back and do it all over again. “It’s a constant cycle to make sure we get to what we were looking for,” he said.
NAACOS noted that Pennsylvania-based TriValley Primary Care, a participant in Tandigm Value Partners ACO, cares for more than 9,000 Medicare beneficiaries in southeastern Pennsylvania. It has developed a scalable, team-based approach to value-based care that combines physician leadership, care management, and population health expertise across practice sites. Its MSSP performance has improved from 6.4% in 2022 to more than 13% in 2024, while sustaining strong quality performance. Strategic partnerships with continuing care retirement communities and the adoption of AI-enabled technology have strengthened care coordination, reduced administrative burden, and improved outcomes for older adults.
Natalie McGann, D.O. medical director for Tandigm Value Partners, said that their basic approach with the ACO is to “do your best to get the patient the care they need at the right place, at the right time, for the right cost. Go to the ends of the earth to keep your patient out of the ER. But when push comes to shove, it's not about the dollars; it’s about making sure that your moral compass is pointing true north.”
McGann said that one key to success is that each TriValley office has a population health specialist whose job it is to make sure care gaps are closed. They also employ teams of care managers. With their population health analytics, the ACO creates a high- and rising-risk report to help clinicians figure out not just who's sick but who's sick and actionable. “We look at it a lot as we figure out: Are we touching these people the right way? Are they enrolled in care management? Are they in the ACO care management? Are they in the practice care management? Are we doing what needs to be done to really help the patients and bend the cost curve?”
Another lesson McGann shared is that you need to invest to earn. “Physicians and particularly independent physicians are thrifty, so it's amazing we have great results on shared savings because we do it on really lean margins,” she said. “But it's very hard to convince them to invest in anything, so you need to be really savvy about what you want, and then you need to push for it. But the truth is you're not going to earn unless you're offloading some of that work with appropriate partners.”
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