Getting Started in an ACO

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Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society.

St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM

Physicians should only claim credit commensurate with the extent of their participation in the activity.

Getting Started in an ACO

Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and ac-crediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME).

This issue of Northeast Florida Medicine includes an article, “Getting Started in an ACO” authored by Pam Maxwell which has been approved for .5 AMA PRA Category 1 credit.TM

For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Pam Maxwell is the Vice President of Provider Development for Orange Health Solutions.

Objectives:

1. To educate healthcare providers about what it takes to create and manage a successful ACO. 2. Provide insight into how successful ACOs positively impact the triple aim of healthcare. 3. Stimulate providers into thinking about how and why they would become part of an ACO.

Date of release: Feb. 1, 2014 Date Credit Expires: Expires: Feb. 1, 2016 Estimated Completion Time: 1/2 hr

How to Earn this CME Credit:

1. Read the “Getting Started in an ACO” article, complete posttest (page 55) and email your test to Patti Ruscito at [email protected] or 904.353.5848.

2. Go to www.dcmsonline.org to read the article and take the CME test online. 3. All non-members must submit payment for their CME before their test can be graded.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. A certificate of credit/completion will be emailed within four to six weeks of submission. If you have any questions, please contact Patti Ruscito at 904.355.6561 or [email protected].

Faculty Disclosure:

Pam Maxwell reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educations activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

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DCMSonline.org Northeast Florida Medicine Vol. 65, No. 1 2014 45

Getting Started in an Accountable Care Organization

Pam Maxwell

VP Provider Development, Orange Health Solutions

Address correspondence to: [email protected]

The increased cost of healthcare in the United States is the driving force of change within the industry. The Accountable Care Organization (ACO) strategy, an important component of the Patient Protection and Affordable Care Act (PPACA), will be effective when opportunities to reduce healthcare costs are taken while maintaining or improving quality and patient satisfaction. As healthcare is evolving away from the traditional pay-for-volume to more pay-for-performance, the primary care provider role has emerged as a leader of patient care management affecting outcomes and driving costs.

ACOs are groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

As of August 2013, almost 500 ACO’s nationwide existed, with more than half of these aligned under the Medicare Shared Savings Program (MSSP). Begun in 2011 with the 23 “Pioneer” ACO’s, the program has expanded as independent physicians groups, hospitals and hospital physicians groups have formed to take advantage of Medicare incentives.

What’s in it for Providers?

The Center for Medicare and Medicaid Services (CMS) has guidelines for establishing an ACO that include a minimum number of 5,000 patients attributed. Based on average benchmark costs at $55 million for the annual treatment of patients (Part A&B) a six percent savings in Medicare expenses can result in approximately $1.7 million revenue shared with the ACO.

Realities for ACO startups from the trenches

Reality #1 – It Takes Money

The estimated cost to fund the operations for 18 months can be as much as $1.5 million or more. These costs include:

• Executive leadership and administration of the ACO • Software and analytics capabilities to effectively interpret the

claims data CMS will share about the ACO’s patient population • Resources to support patient engagement including outreach communication and the possible addition of care coordinators

Reality #2 – You Need Providers

The majority of the participants in a MSSP ACO must be primary care providers, as they will manage the patients. An av-erage of 25 to 50 providers is needed to meet the 5,000 Medicare Fee-for-Service lives. CMS approves which patients are attributed to the providers.

Reality #3 – Financial Incentives are Key

An ACO will need contracts that include aligned incentives to reward providers for achieving the goals of the contract and ACO. An easy place to start is with the MSSP since it is readily available; however, contracts for commercial payers are becoming more common.

Reality #4 – You Must Create Sustainable Results

Sustainable results require a reasonable investment in infrastruc-ture to support the goals of the ACO and its contracts. Even ACOs who have tried to make minimal investments have seen the need for technology and analytics, some basic care coordination, and the required governance and administration of the CMS contract.

The ACO must remain a viable entity throughout the three-year MSSP contract, which requires a laser focus on reducing medical costs and achieving shared savings. Those who don’t reduce cost don’t receive payment from CMS. Reducing costs must not mean withholding care, but focusing on identifying where cost-savings can be made by reducing overutilization and waste. The data showing where spending is high will direct an ACO into actions that will have the most impact. Developing programs that make a difference in how doctors make decisions will lead to minor changes with major cost savings. Sharing best practices across providers within the ACO is encouraged so all participants have a stake in making changes.

The 8 Rules of ACO Medical Cost

1. High costs tend to be high costs 2. Understand the numbers 3. Be aware of benchmarks 4. Do the math

5. Hospitals tend to be expensive sites of care

6. Big groups of cost are easier to work with than small ones 7. Don’t lose time

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A Pioneer ACO in North Florida

Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME).

This issue of Northeast Florida Medicine includes an article, “The Pioneer ACO in North Florida” authored by William Carriere, M.D., which has been approved for .5 AMA PRA Category 1 credit.TM

Faculty/Credentials:

William Carriere, M.D., is the CEO of Family Care Partners.

Objectives:

1. Understand the healthcare industry evolution that lead to the formation of Accountable Care Partners ACO. 2. Understand how the financial incentives align with delivering coordinated higher quality, lower cost healthcare. 3. Understand the infrastructure created in order to achieve success as an ACO.

How to Earn this CME Credit:

1. Read the “The Pioneer ACO in North Florida” article, complete posttest (page 55) and email your test to Patti Ruscito at [email protected] or 904.353.5848.

CME Credit Eligibility:

Faculty Disclosure:

William Carriere, M.D., reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

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A Pioneer ACO in North Florida

William Carriere, MD

VP Provider Development, Orange Health Solutions

Address correspondence to Dr. William Carriere, 6520 Ft. Caroline Road, Jacksonville FL 32277

Overview

Accountable Care Organizations (ACOs) are an important part of healthcare reform. As the first ACO formed in Jacksonville, Accountable Care Partners (ACP) led by Dr. William Carriere, had a unique opportunity to develop and implement strategies for navigating through the complexities of overhauling the healthcare system. Their journey has led them to a set of components vital to the success of ACOs. ACP believes their recipe for success gives physicians the greatest opportunity to seize control of their own destiny in the years to come.

Component I: Recognizing How We Got Here

Many would agree that achieving universal healthcare is a noble and altruistic effort, but a major flaw is that the Affordable Care Act (ACA) merely floods more people into a system that is currently broken and inefficient.

ACOs are only a portion of the ACA. It is designed to control healthcare costs while improving the quality of healthcare given to patients. In order to fully appreciate the ACO’s goals, there must be an understanding of the factors that led the United States healthcare into a compromised position.

Medical rates are mostly paid by governmental and commercial insurances, or “payers.” As the level of medical and technological advancements increased throughout time, the rates for performing them also increased. Providers are the main purchasing agents of these services. As costs began to significantly rise, payers implement-ed controls by cutting the amount they would pay for each service. Rarely, providers compensated for the cuts by performing more tasks and services, to make up for their revenue shortfalls. As the cycle continued, adversarial relationships developed between payers and the providers.

The spending and cutting cycle is not the only culprit for increased financial strain on the healthcare industry. Spending analysis indicates anywhere from 30 to 50 percent of healthcare dollars are attributed to waste producing activities such as dupli-cation of procedures and tests, overutilization, medidupli-cation errors and increased hospital admissions.1

Component II: Information Technology

Physicians in an ACO are held accountable for the entire range of care their patients receive. They must solve failures in the areas of communication, coordination, quality and cost effectiveness. The use of Information Technology (IT) in ACOs ensures accurate tracking of value-based measurements for this payment model. IT provides data gathering and analytic capabilities to stratify

populations of patients, determine cost effectiveness of services, and assist with appropriate clinical decisions.

Component III: The Physician Team

Support is necessary to coordinate the overall care of a patient. Patient outreach, education, engagement, case management, improved access and monitoring of care quality all require atten-tion. In no other way can a physician accomplish all of their new responsibilities without the help of a team. Essentially, these teams support the physician by fulfilling a multitude of background tasks in order to free the physician to concentrate on the most critical decisions necessary for patients.

A growing standard for this form of practicing medicine is called the Patient Centered Medical Home (PCMH). Sponsored by the NCQA, PCMH recognition in a practice comes to those who can prove they are providing the type of coordinated care required to achieve a set standard of quality metrics in patient populations.

Component IV: Payment Reform to Incentivize Change

Finally, physicians must understand that payment based on outcomes, cost effectiveness, and value rather than volume is the theme of many new incentive models.

ACP operates in a shared savings model. At its most basic level, the ACO works with a specific population of patients. Those pa-tients are assigned a budgeted amount of dollars for their annual care among any and all healthcare providers. Payment for services to patients are still made by Fee-For-Service, but if the ACO can satisfactorily achieve a set of evidence-based quality care measures, and do it for less than the overall budgeted amount, a portion of the total savings is then distributed back to the members of the ACO. The remaining savings is held by the payer (in this case, Medicare).

The Challenge and The Opportunity

The obvious challenge for physicians in the coming years is to survive in the old format of Fee-For-Services, or “Volume Based” payment, while implementing the steps necessary for the new “Value-Based” format.

The opportunity for physicians, however, lies in the fact that those who can arm themselves with the necessary data and team can take advantage of the transition and prosper in the savings created by eliminating waste. v

References:

1. Robert Kelley, VP Healthcare Analytics, Thomson Reuters. “Where Can $700 Billion in Waste Be Cut Annually From the U.S. Healthcare System?” October 2009.

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A Payer’s Perspective

Background:

This issue of Northeast Florida Medicine includes an article, “Integrated Health Systems – A Payer’s

Perspective” authored by Jonathan B. Gavras, M.D., which has been approved for .5 AMA PRA Category 1 credit.TM

Faculty/Credentials:

Jonathan Gavras, MD is the Senior Vice President of Delivery Systems and Chief Medical Officer for Florida Blue.

Objectives:

1. Understand why payer industry is move to value-based integrated healthcare. 2. Understand value-based programs that have been implemented at Florida Blue. 3. Discussion of lessons learned from developing value-based models.

How to Earn this CME Credit:

1. Read the “Integrated Health Systems – A Payer’s Perspective” article, complete posttest (page 55) and email your test to Patti Ruscito at [email protected] or 904.353.5848.

CME Credit Eligibility:

Faculty Disclosure:

Jonathan Gavras, MD reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

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Integrated Health Systems - A Payer’s Perspective

Florida Blue

Jonathan B. Gavras, MD

SVP, Delivery System and Chief Medical Officer

Address correspondence to Jonathan B. Gavras, MD SVP, Delivery System and Chief Medical Officer 4800 Deerwood Campus Parkway, Bldg 100, 8th Floor Jacksonville, FL 32246

The United States Delivery System is going through many changes. No one is sure what the full impacts of healthcare reform will be or how the current system of care will evolve. Tremendous anxiety abounds which has led to consolidation and previously unthinkable alliances. One thing is for certain, the changes in healthcare delivery are not fleeting in nature.

Healthcare is local to most people. Their physician remains the anchor and navigator for their care. In the future, quality will be tied to revenue and payment, and will therefore be important in any model moving forward. Patients are more “consumers” of healthcare. They will look for what they perceive as the best value in healthcare.

Payment methodologies are evolving from strictly Fee-For-Service to more value-based care. The previous way of managing costs has not been effective or sustainable. Medical cost trends continue to outpace the Corporate Performance Indicator (CPI). New payment and care delivery models are essential to support coordinated, efficient, and quality-driven healthcare. Some payment innovation domains consist of Pa-tient Centered Medical Homes (PCMH), Accountable Care Organizations (ACO), episode-based/bundled payments, and pay-for performance/quality based incentive programs. Two models have become particularly widespread recently.

The PCMH is a model founded on the patient-physician relationship. The physician is a navigator of members’ care. Models have shown promising results from a cost and quality standpoint. Florida Blue’s PCMH is one of the largest PCM-Hs in the nation. It consists of more than 700,000 members touched and more than 2,200 Primary Care Physicians participating in Florida. PCMH physicians performed same or better than non-participating peers in 100 percent of 29 clinical quality metrics. The utilization of emergency rooms

was reduced by 12 percent. Utilization of inpatient stays was reduced by nine percent, and the overall member per-month cost reduction was greater than four percent.

ACOs are population-based models which focus on the cost and quality of populations of patients. Patients attributed to these models are handled holistically and increased efforts to improve wellness and condition management are paramount. This system is based upon setting a target for quality and cost for a population of patients assigned to a provider entity. Delivery Systems are incentivized to surpass these targets to share in the savings from better overall outcomes in care. Most ACOs are for total cost of care members, but some specialty ACOs exist. An example of this type of model is the Miami-Dade Ac-countable Oncology Program. Oncology costs are very high in Florida, and this program was an attempt to see if it could reduce the medical cost trend. Baptist Health South Florida (BHSF), Advanced Medical Specialties (AMS), and Florida Blue partnered to manage attributed oncology patients. Oncology pathways, after hour care, and increased clinical coordination were the focus. After one year, ER use readmissions decreased and pathway adherence improved. A second oncology ACO was started in Tampa with Moffitt Cancer Center and Florida Blue. Moffitt Cancer Center is a designated National Cancer Institute (NCI) Comprehensive Cancer Center. Moffitt Medical Group contains 330 oncology practitioners in Florida dedicated to cancer care. Similar parameters and structure apply to this program as the BHSF/AMS program.

Over time, the magnitude of U.S. Delivery System will be value-based. This will be essential to a sustainable health care value solution. There are many opportunities to improve the quality and cost of these healthcare models. Improve member engagement, physician satisfaction, and standardized care will continue to evolve and be on the forefront of change within the delivery system. v

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to Improving Health

Background:

This issue of Northeast Florida Medicine includes an article, “An Employer’s Approach to

Improving Health” authored by Chad Greeno which has been approved for .5 AMA PRA Category 1 credit.TM

Faculty/Credentials:

Chad Greeno is the Managing Director for the Healthcare Reform Business Unit at Cerner.

Objectives:

1. Describe the journey that Cerner has taken in improving the health of our associates while decreasing our annual healthcare spend. 2. Present trends in the employer market that are relative to the formation of ACOs combining technology and strategy.

3. Thoughts for partnering directly with employers to achieve outstanding health outcomes at a reduced cost.

How to Earn this CME Credit:

1. Read the “An Employer’s Approach to Improving Health” article, complete posttest (page 55) and email your test to Patti Ruscito at [email protected] or 904.353.5848.

CME Credit Eligibility:

Faculty Disclosure:

Chad Greeno reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

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Employer-based ACOs: How Employers are Systematically

Managing the Health of Their Populations

Chad Greeno, Cerner Corporation

Address correspondence to [email protected]

At its core, an Accountable Care Organization (ACO) is a network of healthcare providers with shared financial responsibility for providing high-quality, coordinated care to a member population. Employers have a defined member population (their employees), and they hold some level of financial responsibility for the health of their employees. However, aside from healthcare organizations like hospitals, not many employers have the resources to close the loop by providing healthcare to their employees. That is changing.

As a direct response to increasing health care costs and changing healthcare policy, United States employers are taking a more active role in their employees’ healthcare. Employers are implementing worksite wellness programs, onsite clinics and are directly contracting to provide value-based care to their workforces. They are, in effect, developing their own ACOs. Many employer-based ACOs are de-creasing health care costs and improving the quality of care received by their employees by employing a data-driven, systematic approach to managing the health of their populations.

Worksite Wellness

One of the most common entry points for employers into direct healthcare engagement is through worksite wellness programs. Most worksite wellness programs consist of health risk assessments combined with biometric screening data to identify risks across a population. The wellness initiatives introduce health education, behavior modification programs, and changes to the physical environment to present more opportunities for making healthy decisions and to create a “culture of health.” The Affordable Care Act has created additional incentives for employers to implement and increase their investment in worksite wellness programs.

A review of literature found workplace wellness programs decrease employer healthcare costs, including medical savings ranging from $11 to $626 per year.1 Healthcare providers are playing a larger role in these worksite wellness programs by providing the assessment and screening systems and staff, and by lending their healthcare brand to the worksite wellness program. This often times improves the employees’ trust and participation in the program.

Onsite Clinics

Worksite wellness programs have benefits, but they also fall short of being able to affect the experience and outcomes related to the delivery of care. Hence, many employers are investing directly in facilities to provide care for their employees and covered lives. Today, these clinics are being developed to provide primary care, as well as some specialized services.

Toyota’s recent investment in a primary care onsite clinic at one of its US locations saw a 33 percent reduction in specialty care costs and a 16 percent reduction in its premium trend. The clinic is now saving the company $3 million per year in health care costs and will realize its return on investment in just two years.

According to a 2012 survey of employers from the National Business Group on Health, 46 percent of large employers offered at least one

onsite clinic to their employees – nearly a 10 percent increase from 2011.2 Additionally, another 10 to 20 percent of large employers have plans to add clinics in the next two years.3 Healthcare providers who are developing clinic and staffing strategies are well-positioned to participate in these important new facets of employer-based ACOs.

Direct Contracts

Despite onsite clinics, a considerable amount of employer healthcare spending still happens in the community. In order to improve the value generated through those community healthcare interactions many employers are turning to direct contracts with providers. These contracts attempt to help shape the quality side of the value equation by establishing measures for member experience, process and outcomes. Some employers seek to establish value-based contracts with providers based on specialty services lines, while some larger employers are contracting directly for total healthcare services.

Walmart and Lowe’s have a set of cardiac-specific programs with Cleveland Clinic, while healthcare technology company Cerner Cor-poration recently announced a first-of-its-kind maternity program for its employees in Kansas City.4,5_{Intel is one of a handful of employers}

who have announced direct contracts with local health systems for narrow-network ACOs (Intel’s partnership with Presbyterian Healthcare Services is called “Connected Care”). A 2013 survey by Oliver Wyman Health & Life Sciences Practice of more than 1,300 employers revealed that nearly 40 percent of employers say they would be interested in contracting directly with provider organizations for a value-based network.

Healthcare providers should view their local employers, regardless of size, as an aggregator of prospective patients who are looking for value-oriented relationships. Without willing partners in their com-munities, these employers are developing independent ACO-like initiatives to engage their employees not only in health, but also in care. Those employers who are demonstrating success in improving health outcomes and controlling costs are taking a systematic approach to managing the health of their populations, and represent a lower risk opportunity for healthcare providers to participate in an ACO arrangement. v

References:

1. RAND Health. 2013. Workplace Wellness Programs Study. Retrieved December 2013, from DHHS, Office of the Assistant Secretary for Planning and Evaluation: http://aspe.hhs.gov/hsp/13/WorkplaceWellness/rpt_wellness.cfm

2. Ferro,S. (2012, August 7). On-site healthcare a growing corporate trend. Retrieved on December 2013, from Treasury & Risk: http://www.treasury- andrisk.com/2012/08/07/on-site-healthcare-a-growing-corporate-trend?t=re-tirement-benefits

3. Anderson,C. (2013, March 13). More large employers adding onsite health clinics. Retrieved on December 2013, from Healthcare Finance News: http://www.health-carefinancenews.com/news/more-large-employers-adding-site-health-clinics 4. Cleveland. (2012, October 11). Cleveland Clinic adds Walmart to Bundled

Payment Program for Employees. Retrieved on December 2013, from Cleveland

Clinic: http://my.clevelandclinic.org/media_relations/library/2012/2012-10-11-cleveland-clinic-adds-walmart-to-bundled-payment-program-for-employees.aspx 5. Cerner. (2013, October 2). Cerner to Offer New Maternity Benefit Program for

Kansas City Associates. Retrieved on December 2013, from Cerner: http://www.

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Home and Ambulatory Intensive Care Unit

in the Accountable Care Organization

Background:

This issue of Northeast Florida Medicine includes an article, “The Role of the Patient Centered Medical Home and Ambulatory Intensive Care Unit in the Accountable Care Organization” authored by

Kenyatta Lee, M.D., which has been approved for .5 AMA PRA Category 1 credit.TM_{For a full description of CME requirements for}

Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Kenyatta Lee, M.D., is the Assistant Dean of Medical Management and Metrics and Associate Medical Director at First Coast Advantages.

Objectives:

1. Understand the history of Ambulatory Intensive Care Unit A-ICU. 2. Review the data demonstrating the effectiveness of the A-ICU. 3. Discuss the future of the A-ICU and role in the ACO.

How to Earn this CME Credit:

1. Read the “The Role of the Patient Centered Medical Home and Ambulatory Intensive Care Unit in the Accountable Care Organization” article, complete posttest (page 55) and email your test to Patti Ruscito at [email protected] or 904.353.5848. 2. Go to www.dcmsonline.org to read the article and take the CME test online.

3. All non-members must submit payment for their CME before their test can be graded.

CME Credit Eligibility:

Faculty Disclosure:

Kenyatta Lee, M.D., reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

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The Role of the Patient Centered Medical Home

and Ambulatory Intensive Care Unit in the

Accountable Care Organization

Kenyatta Lee, MD

Assistant Dean of Medical Management and Metrics and the Associate Medical Director at First Coast Advantage

Address correspondence to [email protected]

According to Medicare, Accountable Care Organizations (ACOs) are groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordi-nated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. The Patient Centered Medical Home (PCMH) has been described as central to ACO functionality because of its demonstrated ability to improve quality and lower the cost of care for patients particularly those with chronic disease. The PCMH model has been in the literature for more than 40 years and promotes the Evidence Based Management of the Ambulatory Practice. The key components of medical homes are improved access, registries, care management, self-management support, referral tracking and continuous quality improvement.

Groups that decide to move forward with participation in an ACO will have to develop robust and dynamic medical homes. The reality, however, is that the medical home model is a significant departure from the current ambulatory model because its focus is value and not volume. Value is described as

quality per unit of cost. Our definition of quality is borrowed directly from the (Institute of Organization Management’s (IOM) six domains of quality. To be successful at value man-agement, practices within an ACO model will have to make the transition from feeders to facilitators of improved quality at lower cost. Consistent with complexity theory, this transition can take some practices two to three years of rigorous and deep practice transformations under the best of circumstances. Most ACO failures occur because they underestimated the time and complexity associated with transformation of volume based practices into well-integrated value producing practices. This underestimation is exacerbated by the fact that many ACO contracts require that the ACO demonstrate measurable sav-ings within the first year. To overcome this challenge many health systems have developed Ambulatory Intensive Care Units (A-ICU) within the ambulatory network. The A-ICU is a model that was developed as a physical location that con-centrates resources in one location. The A-ICU leverages the Pareto principle which states that 20 percent of the patients generate 80 percent of the utilization. The A-ICU works centrally as a hub of the larger PCMH network to provide care for this 20 percent. In this location patients are given full access to providers, social workers and clinical pharmacist that work closely with each patient to decrease emergency room and hospital utilization. v