We quickly found out that we needed timely, actionable data to achieve goals. We recognized that RGVHA’s success would be limited unless we obtained reliable data on our providers’ performance.

Only about a third of the accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) qualified for bonuses in 2017. Our ACO, the Rio Grande Valley Health Alliance (RGVHA), was one of them. In fact, we’ve generated enough MSSP savings to net bonuses for five years in a row.

In 2015, RGVHA saved Medicare $14.2 million, of which our providers received half. In 2016, our ACO’s first year in Track 3 of the MSSP, we received 75% of the $8.5 million we saved. And in 2017, RGVHA saved $9.8 million and earned $6.8 million.

We achieved these consistent results by following a few simple rules:

• We obtained buy-in from our physicians.
• We hired four nurse coordinators who cared for patients between visits to their doctors.
• We built a robust health infrastructure that gave us the data and the analytics we needed to help our physicians fill care gaps, cut waste and improve their performance.

Better data is the key

The initial goals of our ACO were to improve quality of care, reduce costs and increase patient satisfaction, with a focus on high-risk patients. We quickly found out that we needed timely, actionable data to achieve these goals. Also, we recognized that RGVHA’s success would be limited unless we obtained reliable data on our providers’ performance.


We had claims data analyzed by an outside party but found it difficult to create on-demand reports. To remedy this situation and to give our providers more visibility into their patients’ care, we hired a population health management software vendor. We now use this company’s product to aggregate the data from our members’ eight different electronic health records (EHRs) and combine it with claims data. After we analyze this data, using the same application, we deliver monthly reports to the doctors, who can see their patients’ care gaps and the services they receive from outside providers.

These reports form the basis for a face sheet that every doctor receives before each patient visit. This face sheet prompts the physician to provide the preventive and chronic care that the patient is missing. By providing this information to our doctors at the point of care, our ACO raised its MSSP quality scores from 80% to 99% of the maximum.

Data also helped RGVHA control utilization of services. For example, we discovered that our MSSP beneficiaries’ home health spending was four times the national average. Data analysis showed why: some outside physicians were ordering home care that didn’t meet Medicare criteria. After the ACO persuaded these doctors to order home health services only when they were truly needed, our home care costs dropped 41% over two years.

Care coordination

Our nurse care coordinators regularly call or visit their panels of high-risk patients and intervene to prevent their conditions from worsening. They also focus on their patients’ social determinants of health, which can be more important than healthcare in determining patient outcomes. For example, when some patients missed their medical appointments and dialysis sessions, it was the care coordinators who figured out that they lacked reliable transportation. To address this issue, we hired Uber and Lyft to take these patients to their appointments, avoiding emergency room visits and/or hospital admissions in certain cases.


The care coordinators have helped reduce unplanned admissions, especially among patients with congestive heart failure. They have also used their access to both the providers’ EHRs and claims data to reconcile medications and give physicians a more complete picture of each patient’s current drugs.

Physician buy-in

As members of a small, physician-led ACO, our doctors can all participate in the organization’s decisions. Most of them attend monthly meetings in which they have an opportunity to discuss important issues.

The physicians also meet with our care coordinators every week to discuss their high-risk patients. A care coordinator might mention a patient who’s having trouble with a medication, a patient who is not adhering to medications, or someone who is visiting the ED frequently. The physicians usually recommend a course of action or intervene themselves.

Admission rates dropping

Our population health management strategies and the support of our physicians contributed to a marked decline in our ACO’s unplanned admissions (including readmissions) from 2015 to 2016. For patients with diabetes, the rate fell from 48.71 to 44.35, compared to the average performance of 53.20 for MSSP ACOs. For congestive heart failure patients, the rate dropped from 73.67 to 63.71 (vs. the average of 75.23). While we don’t yet have the latest data, our MSSP savings for 2017 suggest that admissions have continued to drop.


Meanwhile, RGVHA has garnered millions of dollars in shared savings from the MSSP. That represents a very significant jump in income for our 24 doctors, after deducting the ACO’s expenses. We’ve joined a larger ACO that has a contract with Blue Cross/Blue Shield of Texas, and we’re seeking deals with other payers as well. We expected continued success as a result of our advanced health information technology infrastructure and our practical approach to care management.

Victoria Farias is program administrator at Rio Grande Valley Health Alliance, a physician-led accountable care organization in McAllen, Texas.