Back in 2009-2010, as the Affordable Care Act was being debated and then passed, Duke Health Systems decided they could not sit on the sidelines and watch as the whole landscape of health care was changing and new models of care were emerging. They needed to take part, but slowly and methodically, they decided, and in a way in which they could learn how to implement a value-based system of care while they were doing it. Thus, Duke Connected Care, a community-based, physician-led network of practices including the Duke University Health System was born in 2014. This is Duke’s Accountable Care Organization (ACO).
“Duke made a conscious decision to explore new opportunities, new models of care and payment,” said Dev Sangvai, MD, MBA, the executive director for Duke Connected Care, associate chief medical officer (ACMO) for Duke University Health System and medical director for DukeWELL (a physician-run population health program for Duke employees and dependents). “We dipped our toe in the water [with Duke Connected Care] with the questions, ‘what are we going to learn from it? What is going to make us a credible citizen in the new health care economy?’”
Not all ACOs have the backing of a major health system as they get off the ground – a definite advantage for Duke Connected Care in both know-how and start-up time.
“Duke had several ongoing care management programs – DukeWELL for the employee population and a few other commercial arrangements, and NPCC [Northern Piedmont Community Care] for Medicaid,” said Eugenie ‘Genie’ Komives, MD, Senior Medical Director for Duke Connected Care. “We also have a robust inpatient care management center for the typical hospital functions like discharge planning and transitions of care. When we moved into the Medicare patient population, we saw the need to enhance the skills and focus of our existing programs (particularly DukeWELL and NPCC) to help serve our Medicare (aging, geriatric, frail) populations.”
Duke Connected Care participates in the Centers for Medicare and Medicaid Services (CMS) Medicare Shared Savings Program (MSSP). Early this year Duke Connected Care contracted with Cigna to become one of the insurance company’s 10 collaborative care initiatives in the Carolinas. The partnership with Cigna benefits over 16,000 individuals covered by a Cigna health plan and receiving care through Duke Connected Care network physicians.
So far, Duke Connected Care encompasses nine practices including small physician groups, a solo practitioner, Duke University Affiliated Physicians and Lincoln Community Health Center, a Federally Qualified Health Center (FQHC) right down the street from Duke University Health System. Together this represents more than 1,200 Duke and select community physicians. Ten to 15 percent of the patients seen through Duke Connected Care are not attributable to the Duke system, Sangvai said.
“We are unique in being a ‘quaternary’ medical center,” Komives said. “Our ACO includes our primary care network, our entire network of Duke specialists (oncology, transplant, nephrology, etc) as well as Lincoln Community Health Center. Much of our attribution comes from patients who are referred in for care from those specialists. We may also have a higher proportion of dual eligible patients than many ACO’s. Both of these aspects create different challenges in terms of patient risk (medical and socioeconomic) than other ACO’s. Understanding how to address patients who become attributed through high cost specialty care as well as those with complex social needs are both challenges for us.”
By the same token, Duke Connected Care benefits from the full spectrum of closely aligned specialists and facilities like post-acute care services.
“If we were able to take full opportunity of [the spectrum of services], it may allow us to develop improved care pathways and processes that may be more of a challenge for a primary-care only ACO,” Komives said. “One example of this is the work we are doing with chronic kidney disease – developing analytic models to predict patients at high risk of rapid progression and using care managers and nephrology virtual consultations to reduce that risk.”
Like other ACO start-ups, physician engagement is key as well as a robust data sharing system. Both take time and resources. Duke Connected Care started with a bit of an advantage with data analytics.
“We had robust analytic shops to manage Medicaid and employed/commercial populations mostly focused on closing gaps in care for chronic illnesses like diabetes, and wellness quality metrics like mammograms,” Komives said, adding that there is an on-going commitment to improve in this area. “We have been working to enhance [the data analytics] to better predict patients who need individual high-touch care management to prevent hospitalizations, re-admissions, ED visits, progression to end-stage renal disease, etc. We have also been working to expand our analysis of variations in care from the inpatient space (where it has been very well developed) into outpatient episodes of care.”
Sangvai notes that while Duke could have “artificially created a set-up for success” with Duke Connected Care, instead the organization is being allowed to develop as organically and independently as possible in the community it serves.
Duke Connected Care was not among those North Carolina ACOs to receive shared savings last year, their first year in the MSSP, but did well in the quality metrics reporting.
“It’s hard work,” Sangvai said. From the broad perspective, Duke Connected Care’s progress has been an affirmation of the ACO approach, he said. On the granular level, however, there will always be numerous issues to address each day.
“We’re part of an academic medical center and it’s a credit to Duke — they could have hung their hat on a lung transplant program, but they’re committed to the community and compelling us to do this work,” Sangvai said.
“The number of [practices that are part of the] MSSP program and the number of ACOs in the state is great for North Carolina,” Sangvai said. “It shows the willingness from many to think differently and think of what’s right for North Carolina. Sure, there are challenges, but overall, it’s a good time for health care in North Carolina.”