Michigan-based Beaumont ACO is working to reduce post-acute readmission rates in collaboration with Chicago-based Puzzle Healthcare, Inc. Azam Afzal, Pharm.D., co-founder and CEO of Puzzle Healthcare, Inc., and Belal Abdalla, MD, CEO and chairman of the board of directors of Beaumont ACO, Inc., recently spoke with Healthcare Innovation magazine about the collaboration.
Beaumont ACO is a joint venture between Corewell Health (formerly Beaumont Health) and about 2,000 physicians, with a network of more than 4,500 physicians participating in the agreement.
Abdalla has served as CEO since the ACO’s founding in 2012. The Beaumont ACO is one of the most successful accountable care organizations in the nation, generating hundreds of millions of dollars in savings for Medicare through Medicare Shared Savings Agreements over the past decade.
Healthcare Innovation: Dr. Abdalla, can you talk about the history of ACOs and how you became involved in this work on reducing hospital readmissions?
Abdallah: When we first formed, we wondered what to do and where to start. In the end, there were a lot of easy jobs. Just doing very simple things like organizing doctors and clinics to make sure patients get seen on time, that they come to the office instead of going to the emergency room. Reviewing medications regularly so that the wrong medications are not prescribed. This was primary care led. They were gatekeepers, but not like the old gatekeepers of the HMO era. This was a new way for doctors to get instructions on what to do and what not to do without being told by administrators. For us, it worked very well. Our guiding principle is physician leadership.
We have been very transparent with physicians about how we do things and how we get money from CMS. We have to build a lot of trust with all our stakeholders, especially the physician practices. We have had great success over the years. Between 2012 and today, we have saved Medicare just over $200 million, and CMS has shared at least half of that with us.
Over the last few years, we began doing an in-depth study to identify where our costs were highest for our patient population. We found that there were very high costs associated with post-acute care, post-discharge, and transitions from the hospital to skilled nursing facilities and other facilities. The primary cause of this was that after the transition, patients were not followed up properly, they were placed in an inappropriate environment, they were not receiving adequate care, and so they were being admitted back into the hospital.
HCI: Have you ever felt like you didn’t really understand what was going on with your nursing home patients?
Abdallah: That’s absolutely true. Before we started looking into this, we had no idea. Patients would be discharged from acute care facilities, and we didn’t know what happened to them after that. We had a system called Patient Ping, so we knew where the patients were, but we didn’t know what was happening to them there.
HCI: Why were you interested in working with puzzles?
Abdallah: Azam told me that Puzzle is pushing the standardization of physical therapy. When I was the medical director of a nursing home 20 years ago, physical therapy was everywhere. A lot of patients were there so that they could get physical therapy after they were discharged, get stronger, recover and go home. If there is no consistency in physical therapy and no real guidance on what the plan is, patients will stay there longer because they are not getting better. And then they end up getting another new illness and getting sicker.
We thought it would help us if we knew there was a facility where our patients could receive standardized physical therapy like Puzzle.
HCI: Azam, can you talk about how you work with skilled nursing facilities? How do you build trust with them?
Afzal: Let me provide a little bit of background. Puzzle is a readmission prevention company and our team has been heavily involved in this value-based care space for the last 10 years. When we engage with systems like Corewell, we take a deep look at system-wide readmission penalties. Typically, the majority of these readmissions come from the post-acute care space, because that’s where typically more severe and critically ill patients are discharged to SNFs.
Although most health systems have preferred post-acute SNF networks that discharge patients based on quality metrics, SNF readmission rates remain very high due to SNF staffing challenges, resulting in poor discharge planning.
We work closely with our health system partners and we collaborate with their post-acute SNF partners. SNFs listen because they want to satisfy their referral sources. They also want to improve the quality of care. We put in place a readmission prevention program that combines physical therapy with care coordination and we put physical therapists as the command center of care in the SNFs because they typically evaluate patients who are at highest risk for readmission.
A multidisciplinary virtual care management team follows patients from discharge to SNF admission, throughout their SNF stay, and for 90 days until the patient is discharged home. Our care managers connect with every patient discharging the SNF to identify exacerbations and conduct disease-specific assessments designed to get a clear, subjective picture of how the patient is doing and if they are at risk for an exacerbation. High-risk patients are then equipped with remote patient monitoring sensors that help track heart rate, breathing, and motor activity levels in real time.
HCI: You say the physical therapist is the quarterback, but are these Puzzle employees or physical therapists already at the SNF?
Afzal: We will have our own physical therapists at the facility, and during post-discharge follow-up, we will work with our health system partners to develop readmission avoidance pathways to triage patients to the appropriate care facility to reduce the risk of readmission.
One of our partners, OSF Healthcare in Illinois, has established eight advanced acute care clinics where care management teams can direct patients if their condition worsens after discharge. We’ve been working closely to develop these diversion pathways and are doing the same with the Beaumont ACO. All of the work we do is aggregated into a post-discharge tracker that risk stratifies every patient after discharge and is shared with the health system, ACOs, and SNFs and discussed in readmission meetings. This has been a great tool to drive awareness and behavior change in the health system.
HCI: Does Puzzle receive compensation from the shared savings, or do health systems pay for the company’s services?
Afzal: We have a lot of shared savings agreements with payers. Once we start working closely with payers, we don’t charge the health system anything. And we don’t charge the SNFs a fee for service because we can provide services on a fee for service basis. From our perspective, the fee for service covers some of the cost. In terms of actual cost, we end up pretty close to breaking even on the service, but we’re always looking to get those shared savings. At OSF Healthcare, we’ve been able to reduce our readmission rate from 29% to 9% in just one year.
HCI: Dr. Abdalla, have you been working on this for so long with Corewell and the Beaumont ACO and are you starting to see early results in terms of reducing readmission rates?
Abdallah: That’s correct. We expect MSSP to be P&L positive again in 2023. We saw an increase in post-acute claims in 2022 and a decrease in 2023. Currently, we don’t have the final results for MSSP yet, but since we started using Puzzle, everything looks set to be positive in 2023.
HCI: Are there still some adjustments you need to make as you further develop your relationship?
Abdalla: Building relationships with all of the SNFs has been a challenge for us. We are a joint venture with Corewell Health, but not all of Corewell Health’s patients are in an ACO. We manage about 325,000 patients in southeast Michigan, but Corewell Health probably admits a lot more than that into the hospital. We decided to work together to form a high-performing skilled nursing facility network that Corewell Health will discharge, and we have certain criteria for joining that network.
Criteria include readmission rates, star ratings, quality, and more. We added items like whether they use Puzzle. If they use Puzzle, they get extra points for joining the network. The physical therapists that Puzzle uses are employed by Puzzle, so they can standardize care. But for facilities that use other physical therapists, you don’t get consistent readmission status from them, so that’s a challenge. But as SNFs began to understand how Puzzle works and the reduction in readmissions, I think we saw more advocates. We’re seeing statistics that show that facilities that use Puzzle have improved readmission rates compared to other facilities.
We’re seeing more buy-in in 2024 and I think this trend will continue, and we’ll be able to really show you post-acute costs going down when we share the savings in early October.
