Today we hear Advocate Health’s Don Calcagno, Senior Vice President and Chief Population Health Officer for Value Operations and Terry Williams, Senior Vice President and Chief Population Health Officer for Partnerships and Strategy who provide insight into Advocate’s participation in the Medicare Shared Savings Program and share with CHESS President and host, Dr. Yates Lennon, the successes that have been achieved along with some of the lessons learned.

Well, Don, Terry, thank you for joining us on the Move to Value podcast today. Glad to have you. If you don't mind, Don, we will let you start and just take a few minutes to tell our audience a little bit about yourself. And then Terry, you go next and the role you play at Advocate Health.

DC: All right, thanks Dr. Lennon. My name is Don Calcagno, I'm currently the Senior Vice President, Chief Population Health Officer for Value Operations for Advocate Health. I also serve as President of Advocate Physician Partners, which is a large, sophisticated, clinically integrated network in the Chicagoland area. Personally, I'm a lab tech by training, completed my schooling in 1992. I have an MBA as well from Northwestern Kellogg and I've been with Advocate for quite some time in various roles from lab tech to others. But I've been a vice President, Operations, Senior Vice President on OPS and I've been either the President or a Senior Vice President of Population Health at Advocate, Advocate Aurora Health since about 2015. So thanks for having me Dr. Lennon. Look forward to the conversation.

Glad to have you. Look forward to it. Terry?

TW: Hi, I'm Terry Williams, Chief Population Health Officer with focus on partnerships and strategy for Advocate Health. And in terms of background, I was Chief Strategy Officer at a couple of health systems for about a decade as well as started Population Health at one of them that we'll talk about a little later today and I'm also responsible for looking at how we can tie together the academic enterprise and some of the innovations that are happening there into what we're actually doing in population health. So, to give you one example, there was something called the EFI Electronic Frailty Index that was developed in the School of Medicine. It's the single best indicator we have found for predicting future utilization. And so, we use that to we think really do some unique work in our population health work by incorporating that measure.

Yeah, familiar with the EFI and I think you just opened the door for a couple more podcasts right there in that one, one statement. So well, one of the things we wanted to do today with you all is to talk a little bit about the MSSP program and Advocate’s participation in that. I know we look forward to hearing about some of the successes as well as the challenges that you all have and are facing. It's interesting the program now is what, 11-12 years old and NAACOS just recently at their fall conference released some stats and I'll read some of those to you. So since 2012, ACO's have saved Medicare 21 1/2 billion dollars in gross savings and 8.3 billion in net savings. So that's since the beginning of the program. For ’22, It was the sixth straight year that ACO's delivered net savings to Medicare. 84% of ACO's in 2022 saved Medicare money and almost 60% of them were in two-sided risk arrangements. So when you think about where this program started and when it started, it sounds like success right, we're moving in the right direction. With that backdrop though, I would love for you all to talk a little bit about Advocate’s participation in MSSP specifically and maybe start, Terry, if you don't mind, start with the story of the Southeast which would be Atrium and Wake Forest and their journey up to ‘22 and then Don you do the same thing for the Midwest and then we'll tackle ‘22 as Advocate as a whole.

TW: OK sure. So the journey for in population health being a really committed journey started 10 years ago in the southeast with Wake Forest, Wake Forest Baptist, which is now Atrium Health. Wake Forest Baptist is part of advocate Health and at that time that was highly unusual for an academic Medical Center to say they were committing to a value-based journey and but there were some thought leaders there that and and I believe that that was what we wanted to do and I was enthused about that and so we stood up a program for the first time. Part of the other unique history here is we decided to partner with a organization that you're familiar with the cornerstone which is set up a company actually that company was CHESS to help guide physician practices and hospitals in the region and beyond to go on a journey to and value based care. There were not a lot of good road maps although you'll hear in a minute from Don Advocate really has had an even longer history and has been doing some amazing work even well before this. But a part of what was stitched together was not only a pop health team, but we said we want to be very intentional on how we work with the Wake Forest Center for Aging, the Center for Alzheimer's, we have a unique division of public Health Sciences there that does some of the largest studies around the world. The Sprint trial for example in blood pressure control was coordinated out of Wake, you might have seen that announced on the news a few years ago. So we said let's we want to bring all that capability together and see if we can go on a journey and really a journey that I consider an academic journey because you're rigorously using data clinical insights to drive change. So that's the history with Wake Forest Baptist. The other three areas in the Southeast in terms of their history all came forward and I'm talking about in Charlotte for example in and in in Georgia is that those population health efforts started about five to seven years ago with different leaders that kind of had a vision for where this needed to go, and in fact the largest ACO in North Carolina is in Charlotte and is collaborative physician alliance. And so there really are some thought leaders spread across two or three states that we brought together to make the Southeast region and then have come together with the Midwest region through our when our we came together about a year ago. And it's just made a really amazing team in terms of experiences, clinicians, administrative folks that just have a lot of lessons to share with one another. And so that's, that's the history that brings us up pretty current to today.

Okay. Thanks, Terry. Don?

DC: Yeah, great. Jump right in. And first one, say thanks for having us on your podcast. You know, the move to value is one of the must listen to podcasts that I have. So, I appreciate the opportunity to actually be on it. As Terry said, great history in the Southeast and then in the Midwest as well. So in the Midwest, Advocate Aurora Health has had this incredibly rich history on value based care that really predates everything back to the 1980s. For those you old enough like myself, you remember that the 90s everyone thought everything was going to be capitated. Well, in 1995, Advocate physician partners, which you'll probably hear me slip and call it APP, was formed. And really that was an inflection point for Advocate Aurora Health. So at that point, we first started as a messenger model where we brought our physicians together, helped them get good rates with payors. But early on, we morphed into a clinically integrated network a CIN, so much so that we had some discussions with the Federal Trade Commission in the early 2000s that landed with the FTC consent agreement.

Those are always fun.

DC: Always fun, but it's really a good spot because it did help us flush out what a CIN should be. But because of our history, we've been taking financial risk since the 1990s. And by that, I mean commercial HMO capitated risk, but then really in the early 2000s as we were morphing into the CIN, we started implementing pay for performance and we kept expanding our metrics. So, our metrics started as primary care, HEDIS, ambulatory, but then we moved to specialists, and we added hospitals, we brought in evidence based medicine, we brought in post-acute. So, our history really is wrong, becoming a clinical integrated network focused on improving quality metrics across continuum with the sound belief that doing good quality care is going to reduce total cost of care. When the ACA came along was being developed, we actually kind of jumped ahead of it for better for where's a PP launched a commercial ACO with the largest payer in the market, Blue Cross Blue Shield, Illinois. At the time, it was one of the first commercial ACO's in the country and it again, it was even before the ACA launched with MSSP. But really at the end of the day, we're going to continue to lean into healthcare transformation that we're talking about MSSP today. But there's commercial ACO's, there's Medicare Advantage, there's other CMS Innovation Center bundles that we're super excited about. And as Terry pointed out, when our organizations come together, it's just the capabilities from both of us come together. We're really gonna drive and really focus on helping people live fully.

Alright, So that gets us up to 2022. And let's talk a little bit about the ACO, the Advocate ACO footprint if you will and recognizing Don and your story of for the Midwest. I mean we're obviously focusing in on a somewhat narrow portion of patient lives in value-based care as we talk about MSSP today because you all have value based agreements across Medicare Advantage and commercial and I'm sure even direct employer offering. So, we're, we're narrowing in on MSSP today. But so how many traditional Medicare ACO's are there were there in 2022 across the Advocate footprint. How many patient lives were covered in those ACOs?

DC: So in 2022, we have 8 active affiliated MSSP ACOs. And I say active now because we do have 3 predecessors that are no longer active. Of those ACO 6 are MSSP and they really range from Track B, which I think everyone's aware is upside only to enhance, which is the most risk we can take. And the way you get to 8, we also have two ACO reach programs, one professional in the Southeast and one global in the Midwest. When you look at the lives, if you just add them all up across the current active ones, we have about 270,000 lives across all of those, if you include when we've had the inactive ones, we're about 350,000 lives. So quite a bit. And to your point, Dr. Lennon is talking CMMI, but we'd be remiss if we also didn't talk about the fact that when Advocate Healthcare thinks about value-based care and Pop Health, we have 4 clinically integrated networks CINs across several States and collectively we're managing 2.3 million value-based lives.

Yeah, yeah. Thank you for pointing that out. That was that dawned on me as we were having that conversation that we really are looking at a narrow slice of value based care work in the enterprise today.

TW: I think one of the reasons, though, that it's an important slice to look at is because there is a similar set of rules across the country that allow people to see how they're doing. When you start moving into the commercial space, everything can, the rules can vary so much by state that it's really hard to see how you're doing. And so I think some of the as we use MSSP as an important measure of how we're doing for our teams, it's helpful that we know that there's kind of a consistent rule set. Now, there's also some wrinkles and maybe we'll talk about that later in terms of how baselines, when they're, when they're set, how they're reset that, that. But in general the rules are similar, quite similar.

Yeah. The other thing we can talk about for just a few minutes if you guys are open to it, if Don, I think you said two enhanced MSSP's I believe and then there are two ACO REACHs? those offer some benefit enhancements which for patients and patient’s families. I think just as important when I think about the skilled nursing facility waiver, these risk programs in the CMS and CMMI models offer some benefit enhancements to patients and their families that get them closer to being on par with some of the benefits that are offered in some of the Medicare Advantage programs. I know in our experience, we have found the skilled nursing facility waiver to be a crowd pleaser for patients. And like I said a couple times already, their families, because they're often times looking at a loved one who is at high risk of a fall, needs skilled care but doesn't qualify for the inpatient stay. And so you're almost waiting for a disaster to happen to get the patient to the care they need. And most of the MA plans do have that three-day waiver, the waiver of the three day stay prior to a SNF. So I don't know if either of you want to take just a minute and expound on your thoughts about how the CMS and CMMI programs can bring maybe even some parity to offerings to MA.

DC: Yeah. You know, one of the things I'd call out and it builds off what Terry said as well is one of the things I fundamentally believe is CMMI programs, MSSP specifically, too many organizations kind of treated as a side hustle versus the way we like to approach it is it's kind of a life cycle. And in in that you you're not just doing it because hey, all the cool kids are doing, but you're actually getting in, you're learning, you're developing capabilities and to your point, you can advance from upside only to maybe a little downside to maybe a lot of downside, right. And that's really how I'd encourage folks to think about it. This is not a one and done. This is not a side hustle. This takes commitment to actually pull off, but to your point, traditional Medicare the way some of the benefits are lined up doesn't really support value-based care and that's why there's some waivers or safe harbors within the regulations so that we can do things much like you discussed the SNF waivers been incredibly valuable you know getting around the three night stay rule and things like that. So, I do think there's probably opportunity for even more waivers as the programs advance. But I also realized you know it's going to be a slow methodical process to get there.

TW: Can I maybe give one other example on how we're really intentional trying to use the talents in a broad way to help drive innovation and and I love your words Don that it's not a side hustle. It's core to what we think is necessary to be transforming for the future, and that is so a few years ago, the Wake Forest School of Medicine Center for Aging was in a study called D Care, funded by PCORI that's specifically looking at how to provide care to patients with dementia, which is a huge and growing issue in this country. A lot of the issues include what happens to the caregivers, often people at home that are taking care of those patients. Well, that study just was releasing its actual results in 2023, while the study and Wake was one of five places in the country that was very much involved in the study with a high degree of patients and providers participating. CMS worked closely with those results over the last couple of years and with PCORI and just announced in this summer the new guide model from CMMI which is the division you know as you know that really creates these new models. Well, because we've been so seriously working on this, we will apply to be in the first wave, which is a pretty high bar and is actually going to create funding for caregivers at home. They'll have an annual payment for some respite time when they need to recharge their batteries at home. And after we've done the first wave in one of our markets, we'll then roll it out across Advocate the next year. And the number of patients and families that are going to be dramatically, positively impacted because of this model and including funding to the for where they haven't had it is going to be dramatic. It will be many tens, 10s of thousands, but that's an example that only through really intentionally tying together the research, being a part of the innovation engine, using that to be first into some of these programs. You don't do that if this is a side hustle, right? You'd kind of wait until others have tried things out and get around. And we said no, we feel a responsibility we've got, we've got talented people. Let's really use it to drive innovation.

Absolutely. Yeah. It's, it's interesting. You brought up the GUIDE model. I'm just sitting here with an inbox message on that that program, and I think our philosophy at CHESS has always been that MSSP is the foundation that's where you begin. It's the beginning of your journey and continues to be the foundation of your journey. So that's great. Well, let's talk a little bit about your outcomes. What did you see across the various ACO's in the Advocate footprint in terms of your outcomes? And if you want to talk in aggregate or individually where you sell pockets of great success, feel free to take that approach as well.

DC: Yeah, I can jump in here. And first, I just want to thank all the outstanding engaged physicians, our clinicians, our teammates, the leaders. I mean we're blessed to have a lot of folks working very diligently to improve the health of our patients that we're privileged to serve. And what's cool about is along the way we're also helping the change the healthcare industry through these different payer models. So a big kudos to the team taking care of the patients. When you zoom out, you see across the six Advocate affiliated, MSSP, ACO's, in 2022, we actually generated $128.2 million in savings and along the way we improve quality and lower total cost of care, so 128.2. So that's quite a bit of money and we're pretty excited about that. But I'll tell you what I think is more exciting is we generated over 3/4 of a billion dollars in savings since the program started. Well, you rattle off some of the stats that NAACOS said. Really moving the needle and we feel we're a big part of leading that. The reason that excites us this is, you know, you talked to me and Terry and our teams, we are so committed to demonstrating to the nation that a transformational health care model that focuses on population health management can improve quality while avoiding total cost of care. So we see MSSP as proof point to that while early in the journey to us, it's just like, hey, this is a real possible point.

Yeah, awesome. Terry, anything to add to that?

TW: Yes, I think that one of the other things that we see because we have a common rule set is our ability to work across our 8 ACO's to share lessons. You have a common language, you had a common rule set and there are innovations happening. Sometimes it says, you know in the home, sometimes it's how we're reducing ED admissions or having some type of specific type of work with...