She shared her insights at the 2015 OPEN MINDS Performance Management Institute event, according to an executive briefing on the Open Minds Web site, FierceHealthcare reported.

Primary Partners, with more than 40 independent practices and 65 provider organizations, was one of the 27 ACO’s  to participate in the first cohort of ACO’s in April 2012. It runs under the advanced payment model, a variation of the Medicare Shared Savings Program (MSSP).

In its first year — the only one for which data are available –Primary Partners  got a 22 percent decrease in the number of emergency department visits that result in  hospital admission. But it didn’t meet some other MSSP performance measures and so didn’t benefit from any shared savings.

Ms. Fusé and her colleagues learned  that a key cost-saving strategy was to identify the “high-utilizer group” in its population and use social workers to coordinate care for them. “One recent study indicated that these super-users’ complex health needs are complicated by their limited care access. However, Primary Partners is ‘still working on perfecting the model’ of data analytics it uses to identify these high-utilizers….”

“Primary Partners also has found that because ACO’s are not eligible for shared savings if they do not retain 70 percent of their populations, the organization’s success hinges on building strong patient-provider relationships to retain its patient base.

Enchanced medication  management to reduce non-adherence as well as committing to tracking patient outcomes are also very important.