Difficile Est Primum Esse: How A Triple Whammy Undermined The Triple Aim

By 2017, the Department of Health and Human Services wants 85 percent of traditional Medicare reimbursements to be based on quality or value, with 30 percent of payments reimbursed through alternative payment models like Accountable Care Organizations (ACOs). Toward that end, the Centers for Medicare and Medicaid Services (CMS) has sponsored several voluntary initiatives, including the Shared Savings and Pioneer ACO models that are thought to be critical to Medicare’s ability to bend the cost curve.

Dartmouth-Hitchcock Health System (DH) is the preeminent academic health system in Northern New England. DH began developing a population health based strategy in 1983 and entered Medicare’s Physician Group Practice (PGP) demonstration project in 2005.

In three of the five PGP demonstration’s years, DH earned incentive payments based on estimated savings in Medicare expenditures. Since then, DH expanded ACO-like models to non-Medicare populations; by 2015, DH had a total of approximately 65 percent of its primary care service population enrolled in, and about 30 percent of its total system net patient revenues generated from, an ACO-like model.