Amy O'Brien Spills the Tea on ACOs, CMS's LEAD and What's Next

[00:00:04] Welcome to HITeaea With Grace, where we spill the tea on HITea. Today, I'm honored to welcome to the pod Amy O'Brien, Senior Vice President of Growth Post-Acute at Sound Physicians. Thanks for joining me today, Amy. Amy O'Brien Thanks for having me, Grace. I'm really excited about this. Amy O'Brien Oh, we're so thrilled to learn from you. So tell us a little bit about your career journey and what brought you to your role today. Amy O' Sure. It was sort of a unique journey for me. I've always had an interest in people, learning about people.

[00:00:33] Amy O' In fact, I went to school to be anthropologist, although my secret desire is to be a paleontologist, but that's for when I don't have to adult. Amy O' But went into anthropology, just really interested in people, cultures, how the world works together, and found myself, oddly enough, in the medicine field through the Medical College of Wisconsin.

[00:00:54] Amy O' And earned my stripes in with a little bit of patient care, a little bit of back office. Really enjoyed the patient care, the hands-on aspect of that, and just kind of kept wanting to learn more about the healthcare space. Amy O' And so I took on insurance, I took on business development, I took on recruitment. Amy O' And then sound sort of plucked me almost five years ago now and said, we've got this value-based care program.

[00:01:20] Amy O' We think your background is very interesting. Would you be interested in something like this? Amy O' And that evolved into accountable care, which I had never heard of until that point. Amy O' And it's just been such a fun journey and a unique one, like I said. Amy O' Oh, I love to hear it. So tell us, for those who aren't familiar, what does an ACO do? Amy O' Sure. So an accountable care organization, and it's funny you asked me that question because my family has always asked me, what do you even do?

[00:01:47] Amy O' So the way I simplify it is the government CMS is looking for a way to really manage costs in the geriatric patient population, our Medicare beneficiaries. Amy O' So as an aggregator, as a program leader, our goal is to leverage the data that's coming in, leverage our expertise with providers in the field delivering the care, and help them really streamline

[00:02:17] Amy O' And coordinate the care that's being delivered to help reduce that cost of care, but not negatively impact the quality of care that's being delivered. Amy O' Wow. So what are some of the challenges you've been seeing then that are associated with working with high acuity patients doing that work? Amy O' So interestingly enough, our ACO took a different angle on the Medicare beneficiary.

[00:02:43] Amy O' So you've got your standard walkie talkie beneficiary. They still live independently. They can drive themselves to their physicians, and that's the bulk. Probably 97% of ACOs in existence today. Amy O' Our ACO has taken sort of a microscopic lens on the custodial patient. So the ones that live in nursing facilities, assisted living memory care, those are truly the highest complex patients.

[00:03:10] Amy O' One of the biggest challenges that I've seen, just from an outside looking and not being the clinical delivery person, is helping get the quality metrics for our particular patient population to make sense.

[00:03:25] Amy O' As it stands, all ACOs have the same quality metrics to report on the same goals of care. And you probably know this, right? Just looking at your own personal life, what works for you isn't necessarily going to work for me. And so if we just take a step back and help the program evolve in such a way that it makes sense, I think it'll be better for everybody. But that, I would say is one of our biggest challenges.

[00:03:54] Amy O' Yeah, that makes a ton of sense. And on that front, what do you see as the biggest opportunities for improvement then in value-based care in the next five to 10 years? I know ACO Reach is being phased out, and CMS's new lead model is launching next year, which I know you guys have applied for. So kind of looking into the future, what is the future of value-based care? How is your organization adapting its risk and care strategies for that particular transition?

[00:04:20] Amy O' Great question. And I think one of the things that really sets us apart is we are actively engaged with Congress and our leaders in government to actively review the rules of the program to make them make sense. Amy O' We have our chief medical officer, Dr. Tom Kim, and then we have a VP of strategy and policy, Tom Bednar, Tom Squared, that are going to the Hill advocating on behalf of these beneficiaries so that it's not a five, 10-year plan, it's more immediate.

[00:04:49] What can we start doing in performance year 28 that will have a positive impact on the care that's being delivered and how the program is shaped? Amy O' You mentioned LEAD, and yes, we're really excited to say that we have been conditionally approved for the LEAD program. We are waiting for final confirmation as CMS just closed their portal, and so they're doing all their final reconciliation.

[00:05:14] But we're really excited about that because it opens the door for a completely separate patient population.

[00:05:21] Amy O' So we're focused on the homebound senior. So the program from our lens is really intended to help those beneficiaries age in place. We all know how important it is to bring care to the patient and meet them where they're at. And there's so many more beneficiaries out there who just want to stay home and get the care delivered to them at home.

[00:05:49] Amy O' And so we're really excited to have that be really a focus of our LEAD efforts. Amy O' Very interesting. Now, a lot of my followers are huge interoperability nerds. So we got to talk a little bit about interoperability in relation to what you are doing. So we know interoperability and data sharing between payers, providers, and post-acute settings is a huge pain point. So what do you think would meaningfully move that needle for ACOs trying to coordinate care when it comes to that?

[00:06:16] Amy O' So that is another great question. And you said interoperability and my heart cringed. It is definitely a pain point for I think all ACOs out there. When the systems aren't talking to each other, it's really hard for the providers, the boots on the ground to coordinate that care.

[00:06:32] Amy O' What I do think is working is when you are aligned in an ACO, that ACO is receiving all of the information, all of the data from all of the sources to create that global view of what's going on for that unique beneficiary, that one patient. Amy O' It's up to the ACOs to sort of filter through the noise and create actionable data and reporting for those ACO participants.

[00:07:01] Amy O' But what I think would be really meaningful, and maybe this is a little bit crazy, can we reduce some of the cost of integration? Amy O' Can we just make it simpler for our providers to access the care that they need to deliver good care? Amy O' We shouldn't have to charge an arm and a leg to have access to data. There's got to be an easier way. So lofty goals, but...

[00:07:26] Amy O' Yeah, and gratefully, you guys are at the forefront of like really trying to help make that happen and make that change happen, which is encouraging for us to hear that too, and knowing the challenges you all face. Amy O' With Medicare Advantage continuing to grow relative to traditional Medicare, how is that shift playing out in the long-term care space specifically? And how is it changing competitive and financial landscapes for ACOs working with those populations?

[00:07:50] Amy O' So another interesting question and part of my unique background is I do come from the insurance space as well, specifically the ISNP world. So as you probably are aware, there's Medicare Advantage plans for community Medicare beneficiaries, your standard Medicare Advantage plans. Amy O' And then you have these ISNP plans, institutional special needs programs, and the institutional equivalent special needs program, IE-SNP, for your assisted living members.

[00:08:19] What I love about the diversity of value-based care programs for our seniors is there's not one solution that's going to fit everybody. Amy O' So as a facility operator, when you're looking at how do I enter into the value-based care field, my recommendation is always diversify your interests, right? You wouldn't put all of your money into one stock. You really want to spread that out and see what's working for your patient population.

[00:08:47] Amy O' I think that Medicare Advantage plans, whether they're ISNP or the traditional MAPs and ACOs can work together in a lot of these buildings for these residents. The difference from an economic perspective is that from a Medicare Advantage plan, you are actively enrolling the patient. They are disenrolling from traditional Medicare to select and ensure to manage those benefits.

[00:09:13] Amy O' From a receiver, clinical delivery person building, I'm now kind of being held to a monthly stipend, if you want to, right? It's a PM per beneficiary per month limit or cap that you have to manage this person's benefits within and their health. An ACO has an annualized spend.

[00:09:37] So we know that, especially with our patient population, we're going to have acute events that create costs to spike. But by and large, that patient is really stable, and so it's going to even itself out. So again, I think diversifying and having both of these plans available on ACO, we're not changing their benefits. They don't have to disenroll from Medicare. It makes sense for people who, as I lovingly say, have the Cadillac of retirement plans as a supplemental. It makes sense for them to stay on that.

[00:10:07] And so they can passively align to a value-based care program that's going to elevate that level of care that's being delivered. Yeah, that makes a ton of sense. That's a great picture of what, that just makes a lot of sense. I'll cut that out. Now, while my listeners love to hear about the industry, what they also love to learn about is what drives amazing women leaders like yourself working hard to really change the landscape in healthcare.

[00:10:34] So what are things that you do to work your best and make a difference? Do you have any habits or things that you do in your day-to-day that just keep you at the top of your game? Four shots of espresso in the morning, always. No. Beyond that, though, I have found that healthcare is just what drives me. I spent a lot of time in geriatrics throughout my healthcare career. And it's one of those industries where you are either in for life or you find out very quickly it's not a good fit for you.

[00:11:02] I find that I am super passionate about the work that we are doing. And I've been told that I'm very positive and I come with a lot of energy to what I do. And I think because people are telling me this, the people I'm interacting with can feel that and they get that energy. And I love hearing from our beneficiaries, from our clinicians, from our facilities who are like, wow, I didn't know value-based care could be like this. I didn't know that there was economics involved.

[00:11:32] The star ratings have gone up. My patients are happy. The families are happy. And that's truly what motivates me is just knowing that we're out there doing really great work. Yeah, you clearly have a very strong North Star. And your positivity and perspective is inspiring those around you to keep going. Because you're trying to change something. That's not easy. You're going up hard both ways. If you could give your younger self a piece of advice, what would you tell her?

[00:12:01] Stay true to yourself always and go with your gut. I feel like I've never really swayed from who I am. And the people that are meant to be in your circle and influence you will come to you. If you just maintain who you are, just be true to yourself. To finish this conversation off right, where can our listeners find you online? Great. Great. Yeah. So the best place to find me is going to be on LinkedIn. Pretty active on the LinkedIn social media piece there.

[00:12:28] But you can also find us on my website or our sound's website, soundaccountablecare.com. Terrific. Now, before I forget, did you happen to bring tea with you today? I did not. Do you have a mug near you? I've met in coffee. Oh, I love it. And it's a great Starbucks mug. Tell me a little bit about your mug. So I travel a lot for my job, as you can imagine, and growth. And I found this reusable cup at one of the Starbucks. It was actually at the DC airport.

[00:12:58] And I loved it because I got it on... It was Earth Day. And it's my daily espresso cup now. Every day, my husband is begging me to throw this away. And I cannot because it's my coffee mug. I know. I love it. I actually have a Starbucks mug with me today, too. I have the pumpkin anthropology thing for fall. So anyway, go Starbucks. I love when we can find one that matches your personality and what you like and just brings you a smile at the start of your day.

[00:13:27] Well, thank you so much, Amy, for joining us. It was awesome learning from you. Thank you so much for having me. I appreciate it. And thanks to you folks for joining us, too. Check out the High Tea with Grace podcast for more interviews with great guests like Amy today. Cheers. Like a Girl Media is more than a media network. It's a community. We want to meet you and amplify your voice and the voices of outstanding women innovating in health care. Interested in starting your own podcast or hosting an event near you? Connect with us online or in person.

[00:13:57] We're here to support and empower you.