Jun 24, 2015

Accountable Care Organizations: A Look at ACO Design and Implementation

Accountable Care Organizations: A Look at ACO Design and Implementation from kmarple

Source : SlideShare


  • 1. Accountable Care Organizations
    A Look at ACO Design and Implementation
    Keith Marple
  • 2. Accountable Care Organizations
    Theory of ACOs
    ACO Examples
    CMS Shared Savings Program Legislation
    My Take
  • 3. Theory of ACOs
    Defined by Elliott Fisher, MD/MPH in 2009
    Seeks to address the following problems:
    Current Incentives and System
    Fragmentation prevent providers from
    managing the health of their patient population
    Provider incomes are tied to service volume and intensity
    Patients believe that more care is better care
  • 4. Theory of ACOs
    Fisher’s Solution
    ACOs care for patient populations using integrated care teams, evidence-based medicine, and a focus on primary care.
    Legal Provider Entity
    Attributable and Significant Patient Base
    Invisibly assigned by empirical methods
    Risk-Adjusted Cost Benchmarks
    Quality Measurement and Reporting
    Shared Savings
  • 5. Some ACO Examples
    Some examples I’ll cover…
    CMS Physician Group Practice Demonstration Project
    Geisinger Health System, Danville, PA
    Montefiore Medical System, Bronx, NY
    And some in Massachusetts you probably already know about…
    Commonwealth Care Alliance
    BCBS Alternative Quality Contract Participants
    Caritas Christi Health Care
  • 6. CMS Physician Group Practice Demo
    2005 Demonstration Program to test ACO concept
    10 large physician groups chosen
    Focused on management of diabetes patient population
    Fee-for-service payment plus payment incentives for cost and quality results
    Results in Year 1
    All 10 groups improved quality of diabetes management
    8 of 10 experienced lower cost increases than national average
  • 7. Geisinger Health System
    Integrated Delivery Network Located in rural Pennsylvania
    Includes Health Plan with 250,000 covered lives, which allows Geisinger to be financially incentivized for low-cost, high-quality care
    Introduced ProvenCare model:
    Standard, evidence-based care processes
    Surgical checklists
    Money-back “Warranty” on complications
    Introduced with CABG surgeries, rolled out to other acute services
  • 8. Geisinger Health System
    Introduced ProvenCare Navigator for Case Management
  • 9. Montefiore Medical Center
    Includes 1,500 bed medical
    center and health plan with
    150,000 covered lives
    Located in poor urban neighborhood in the Bronx
    (27% below poverty line)
    Provides in-home and remote case management and chronic disease management, even with low commercial payments
  • 10. ACOs in Practice: The CMS Shared Savings Program
    Section 3022 of the Patient Protection and Affordable Care Act: CMS must establish a “Shared Savings Program” by 1/1/2012
    Final CMS rule scheduled to be published this December 2010 (Update: actually published 3/31/11)
    Participants must have:
    Formal legal structure
    PCPs with 5000+ Medicare patients
    3 year commitment to program
    Information systems to manage care and reporting
    Processes to provide evidence-based care and coordinate care across the ACO
  • 11. ACOs in Practice: The CMS Shared Savings Program
    ACO must take responsibility for >5000 Medicare beneficiaries
    Beneficiaries must be notified at time of care
    Patient cannot be limited to ACO provider network
    Shared savings available in two tiers:
    Low risk (shared savings in years 1-3, shared losses in 3)
    Up to 50% of saved dollars above 2% threshold
    More risk (shared savings and losses in years 1-3)
    Up to 60% of all saved dollars, up to 10% of shared losses
    Savings only available when reported quality benchmarks are met, and savings amounts based on total quality score of ACO
    Anti-trust and kickback laws exempt for shared savings $$
    HHS estimates $960 million in savings
  • 12. My Take on Shared Savings Program
    “Voluntary and Incremental”
    A good first step. The lack of a closed network is limiting but…
    Effects on cost and quality will be muted but still evident
    Commercial payers will follow suit, multiplying incentives
    Existing providers will be moderately successful
    By improving quality and reducing unnecessary and duplicative services
    But at the cost of excessive restructuring costs and losses
    Tightly integrated PCP networks best positioned (Harvard Vanguard)
  • 13. What’s Next
    New capital will be infused in the market for:
    Reclamation projects of struggling systems including PCP networks(ex. Caritas Christi)
    With nothing to lose, the change process in these systems will be greatly aided
    Brand new systems designed for prevention and low-cost, high-touch mid-level care teams
    Follow-on legislation will include
    Full capitation
    Limited networks
    Rate setting?

Explaining Accountable Care Organizations (ACOs): Key Strategies for Educating Constituents

Source : | SlideShare


  • 1. Explaining Accountable CareOrganizations (ACOs): Key Strategies for Educating Constituents Boehringer Ingelheim Patient Advocacy Relations Web Conference Agenda July 31, 2012 Lee B. Sacks, MD
  • 2. AGENDA• Introductions and Goals• Introduction to ACOs• Communicating with Health Care Providers Lessons Learned Challenges• Communicating with Patients• Questions and Answers2
  • 3. New Payment Models Incentivize Value and Accountability High Insurance product Prepaid/capitation Degree of Complexity Shared savings/global budgets Condition-specific budget/medical home Bundled payment for episodes of care Bundled payment for acute care (inpatient only) P4P/value-based purchasing Inpatient case rates (eg, DRGs) Fee for service Low Scope of Risk HighP4P = pay for performance; DRG = diagnosis-related group. 3
  • 4. Accountable Care Organizations* • Strategy to “Bend the Cost Curve” and Improve Coordination and Quality of Care • Implementing a Learning System – Strategic Focused Goals and Objectives – Skills and Tools – Measurement and Accountability – Leadership *Shortell, Stephen M., Lawrence P. Casalino, Elliott S. Fisher How the Center for Medicare Innovation Should Test Accountable Care Organizations Health Affairs 29. No 7 pp. 1293 - 129844
  • 5. Accountable Care Organization • Affordable Care Act required HHS to create ACOs by January 2012 • Provider Groups accept responsibility for cost and outcomes for a specific population • Must provide data to be used to assess performance • Attribution / Alignment 55
  • 6. Federal ACO Requirements • “Become Accountable for • Report Key Data to HHS: Quality, Cost, Overall Care” of Assignment, Quality, Etc FFS Beneficiaries • Leadership and • At Least 3 Yr Contract Management Structure • Formal Legal Structure to • Processes to Promote EBM, Receive/Distribute Shared Patient Engagement, Quality, Savings Cost, Care Coordination • Enough Primary Care for • Meet Patient-Centered Assigned Beneficiaries (At Criteria Least 5000)6 6
  • 7. CMS Description of MSSP• New approach to health care delivery• Provider organizations become accountable for quality, cost and service to defined group of Medicare beneficiaries (Medicare Parts A and B services)• Encourages investment in infrastructure & redesigned care processes• Providers with attributed patients may only participate in one ACO• Medicare shares savings with ACO• Patients continue Medicare FFS benefit and retain their ability to choose any provider7
  • 8. What MSSP Isn’t . . .• MSSP is not a bundled payment program• MSSP is not a capitated payment program• Physicians and hospitals continue to submit fee- for-service bills to Medicare• Physicians and hospitals continue to be paid by Medicare using the Medicare fee schedule – No FFS payments are sent to ACO• No assignment of Medicare patients to PCPs – CMS attributed patients retrospectively based on physician services provided during the year8
  • 9. MSSP Contract Structure• 3½ year contract starting July 1, 2012• Retrospectively attributed beneficiaries with prospective data sharing• Shared savings with no downside (repayment) risk• Up to 50% share of savings based on quality score9
  • 10. Status Through July 2012• 154 Organizations Participating in Shared Savings Programs (2.4 M beneficiaries) – 32 Pioneer – 6 Physician Group Practice Transition Demonstration – 27 April 1 Medicare Shared Savings Program (MSSP) – 89 July 1 MSSP (1.2 M beneficiaries)10
  • 11. Challenges for ACOs • Large Multi-specialty Groups are the Exception • 9 of 10 Americans Get Their Medical Care in a Solo or Small Practice* • Infrastructure is Required to Drive Quality Outcomes Demonstrated by Multi-specialty Groups • Culture is not Created Over Night • Patient Mistrust or Misunderstanding *NEJM 360;7 Feb. 12, 2009 1111
  • 12. MSSP Is Good for Patients &Physicians• Infrastructure to support coordinated care management across the continuum – Outpatient care managers follow complex patients to support access to appropriate care – Inpatient care managers coordinate care and provide communication to the patient’s family – Transition coaches assist patients in follow-up with their physician following discharge• Patients retain full FFS Medicare benefit12
  • 13. Changing Paradigms From TOSilo Care Management Enterprise Care ManagementEpisodes of Care Coordination of CareDischarges TransitionsUtilization Management Right care, at the right place, at the right timeCaring for the sick Keeping people wellProduction (volume) Performance (value)13 13
  • 14. Clinical Integration is the Foundation of an ACO• Provides Infrastructure for Integration of Small Practices• Overcomes Problems Seen Within the Fee- for-Service Model – Incentives to Providers Drive Improvement• Creates Business Case for Hospital and Doctors to Work for Common Goals• Allows One Approach for Commercial and Governmental Payers14
  • 15. What Clinical Integration Looks Like Jane Smith, OB-GYN Patient with Diabetes Mammography Endocrinologist Lab Test Results Primary Pharmacy Care Physician APP Data Warehouse and Disease Registries Primary Care Physician • OB-GYN • Endocrinologist15
  • 16. Clinical Integration 4.0:Increasing Physician/System Integration Clinical Integration to Increasing Accountable Primary Physician/ Care Care/ System Ambulatory Increasing Integration Measures Specialist Measures Maturing Years: Health Reform: Early Years: Middle Years: 2010 - 2011 2012 - ongoing 2004 - 2006 2007 - 2009 16
  • 17. Creating a Culture of EngagedPhysicians• Physician Engagement in Governance• Physician Leadership Development• Shared Identity and Values → “Membership”• Infrastructure Investment to Enable Success• Appeals to Pride and Sense of Excellence – Recognition for Quality and Efficiency – Consistent Use of Evidence-based Medicine – Power of the Outcomes of the Group17
  • 18. ECM Infrastructure & Support Physician Office Communication Performance Strategies Coaches Outpatient Care Management • Dedicated Outpatient PCP CMs for High-RiskAccess/Virtual patients Market Share Visits Growth/Backfill Emergency/Acute Post Acute Care Management • SNF CM Model • Inpatient CMs • SNF, LTACH, • ED CMs Inpatient Rehab • Hospitalists Network • Physician-Partnered • Transition Coaches CM Model CM Data & Analytics Risk/Reporting System 18
  • 19. Achieving Savings• Inpatient Hospital Utilization Potentially Avoidable Admissions Readmissions• Imaging – MRI, CT, PET, Nuclear Medicine• Post Acute – Skilled Nursing Home Length of Stay – Home Care Services19
  • 20. Sharing Savings Issues• Pay for Performance is the catalyst for clinical integration• Physicians versus Hospitals• Primary care versus Subspecialists• Replace lost revenue vs incentive for work20
  • 21. In Network Care Coordination• Electronic Medical Record Available• Avoids Duplication• Better Communication and Handoffs• Access to Care Managers• Variety of Access Points• Cost Effective for Patient21
  • 22. Challenges of PatientCommunication• Medicare Rules• Physician Office is key resource• Customize for condition, cultural issues, etc.• Keep in mind – “What’s In It For Me”22
  • 23. Challenges of PatientCommunication• Resources – Outbound Call Center – Targeted Mailings – Web Site – Coaches – Care Managers – Asynchronous / Virtual Visit- E Mail – Group Visits23
  • 24. Questions?