Accountable Care Organizations (ACOs)

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Accountable Care Organizations (ACOs)

  1. 1. Accountable  Care  Organiza2ons  (ACOs)   Wednesday,  January  29,  2014   Disclaimer:  Nothing  that  we  are  sharing  is  intended  as  legally  binding  or  prescrip7ve  advice.  This  presenta7on  is  a   synthesis  of  publically  available  informa7on  and  best  prac7ces.  
  2. 2. Accountable  Care  Organiza,ons   (ACOs)   •  Builds  off  Pa,ent-­‐Centered  Medical  Home   –  Coordinated  care  to  ensure  seamless  transi,on   between  services  and  levels  of  care   •  Formalizes  Pa,ent-­‐Centered  Medical   Neighborhoods   –  Brings  together  primary  care  physicians,   specialists,  and  hospitals   •  Reimbursement  amount  linked  to  quality   •  Launched  in  2012  
  3. 3. ACO  Overview   •  Model  for  delivery   •  Voluntary  virtual  conglomerate   –  For  providers  serving  Medicare  beneficiaries   –  Shared  responsibility  amongst  coordinated  healthcare   providers     •  •  •  •  •  High  quality  care   Curtailing  growth  of  healthcare  costs   Shared  accountability  for  pa,ent  health  outcomes   Comba,ng  overu,liza,on  of  healthcare  services   Improved  value  of  care   –  Financial  incen,ve  from  money  saved  
  4. 4. Key  Design  Features  of  an  ACO     •  •  •  •  •  •  •  Accountability   Organiza,on  and  Governance   Primary  care  focus   Sufficiently  sized  pa,ent  popula,ons   Investment  in  delivery  system  improvement   Shared  saving   Performance  Measurement  
  5. 5. Success  Criteria  for  ACOs   •  •  •  •  Leadership   Teamwork-­‐oriented  organiza,onal  structure   Synergis,c  provider  rela,onships   IT  infrastructure   –  Popula,on  analy,cs  and  management   –  Coordina,on  of  care   •  •  •  •  Quality  indicators   Financial  risk  management   Pa,ent  educa,on  and  support   Financial  infrastructure  
  6. 6. Fundamentals  of  an  ACO     •  •  •  •  •  Leadership   Organiza,onal  commitment   Upfront  investment   Informa,on  flows  and  technology   Care  management  strategies  
  7. 7. ACO  Technology  Infrastructure   Enterprise  Revenue     Cycle  Management   Electronic  Health     Record         Pa,ent Engagement Informa,cs   Health  Informa,on   Exchange  
  8. 8. Technology  Considera,ons   Pa,ent   Engagement   Data   Aggrega,on   Popula,on   Health   Management   Privacy  and   Security   Clinical  and   Administra,ve   Date  Exchange   Performance   Management   Repor,ng   Infrastructure   Finances  
  9. 9. Startup  Costs   •  Startup  costs  reported  by  the  Na,onal  Associa,on  of   Accountable  Care  Organiza,ons  (NAACOS)   –  Average:  $  2  million   –  Range:  $300  thousand  -­‐  $  6.7  million   –  Excluding   •  •  •  •  Feasibility  studies   CMS  applica,on   Legal  fees     Other  pre-­‐contract  costs     –  Higher  than  CMS  es,mate  ($1.8  million)   –  Less  than  AHA  es,mate  ($11.6  to  $26.5  million)   –  Financial  risk:  $  4  million  in  first  year  
  10. 10. Startup  Cost  Categories   Network   Development  and   Management   Human  Resources  and   compensa,on     Care  Coordina,on,   Quality   Improvement,  and   U,liza,on   Management   Disease  registries   Clinical  Informa,on   Systems   EHR   Legal  and  consul,ng   support   Financial  and  MIS   systems   Recruitment  and   restructuring   Care  paeern  analyses   Care  Coordina,on   intra-­‐system  EHR   Disease  Management   Strategic  partnerships   Post-­‐acute  care   Data  Analy,cs   Quality  Repor,ng   PCMH  Cer,fica,on   HIE  
  11. 11. Startup  Costs  by  Beneficiaries   Es2mated  Start  Up  Costs   3,000,000   2,500,000   2,000,000   1,500,000   1,000,000   500,000   0   5,000  -­‐  15,000   16,000  -­‐  25,000   Aligned  Beneficiaries   26,000+  
  12. 12. Costs   IT  Costs   1,000,000   900,000   800,000   700,000   600,000   500,000   400,000   300,000   200,000   100,000   0   Internal  IT   External  Vendor   5,000  -­‐   10,000   10,000  -­‐   15,000   15,000  -­‐   25,000   Aligned  Beneficiaries   26,000+  
  13. 13. Es,mated  Savings*   •  •  •  •    13  ACOs  broke  even   9  ACOs  gained  an  average  $1.3  million   6  ACOs  lost  an  average  of  $1.3  million   6  ACOs  did  not  know  or  did  not  report     * Source:  Na7onal  Associa7on  of  Accountable  Care  Organiza7ons  (NAACOS)
  14. 14. Opera2onal  Challenges   Other   22%   CMS  Data   40%   Out  of  Network   Use   7%   Quality  Repor,ng   11%   Governance   9%   IT  Opera,ons   11%  
  15. 15. ACO  Accredita,on   •  NCQA   –  Standards   •  •  •  •  •  •  Pa,ent  access  to  care     Pa,ent  rights  and  responsibili,es     Primary  care     Care  management  and  coordina,on  capability   Prac,ce  paeerns  and  performance  repor,ng     Program  opera,ons     –  HEDIS   •  Clinical  Quality  Measures   •  Efficiency/overuse/u,liza,on   •  Pa,ent  experience  
  16. 16. NCQA  Evalua,on   •  •  •  •  •  •  •  ACO  structure  and  opera,ons   Access  to  needed  providers   Pa,ent-­‐Centered  primary  care   Care  management   Care  coordina,on  and  transi,ons   Pa,ent  rights  and  responsibili,es   Performance  repor,ng  and  quality   improvement  
  17. 17. Medicare  Shared  Saving  Program   (MSSP)  Eligibility   •  Applica,ons  accepted  annually   –  No,ce  of  Intent  must  be  filed   •  Summer  2014   •  Three-­‐year  term   •  Applica,on  must  demonstrate   –  Ongoing  quality  assurance  and  improvement   –  Prac,ce  of  evidence-­‐based  medicine   –  Pa,ent  engagement   –  Care  coordina,on   •  Decision  regarding  one-­‐sided  or  two-­‐sided  ACO  
  18. 18. One-­‐Sided  vs.  Two-­‐Sided  ACO   One-­‐ Sided   •  Annual  shared  savings   payment   •  No  penalty  for   expenditures  exceeding   benchmark   •  First  three  years  only   Two-­‐ Sided   •  Penalty  for  expenditures   exceeding  benchmark   •  Higher  payment  if   expenditures  are  less  than   benchmark  
  19. 19. What’s  Next?   February  5,  2014  –   Physician  Quality   Repor,ng  System  (PQRS)  
  20. 20. Q&A   dan.holleran@quirkhealthcare.com   tamina.vahidy@quirkhealthcare.com  
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