NPRM released March 31, 2011Accountable Care Organization (ACO) means a legal entity that is recognized and authorized under applicable State law, as identified by a TIN, and comprised of an eligible group of ACO participants that work together to manage and coordinate care for Medicare FFS beneficiaries and have established a mechanism for shared governance that provides all ACO participants with an appropriate proportionate control over the ACO’s decision making processACO participant means a Medicare-enrolled provider of services and/or a supplierACO provider/supplier means a provider of services and/or a supplier that bills for items and services it furnishes to Medicare beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare rules and regulations
In March of ‘10 PPACA was enacted, The HCERA was then enacted which amended it. Together, they are known as the Affordable Care ActDefinition of the Shared Savings Program, “a program that promotes accountability for a patient population and coordinates items and services under Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery”
Links payments directly to the quality of care deliveredRewards providers for high quality, efficient careImprove QualityUse of adjusted outcome and patient experience measuresMeasures aligned cross Medicare and MedicaidAligned with MU measures and best practicesLower growth in expendituresReward providers for reducing unnecessary expendituresContinual improvement of qualityUse of ongoing cost reducing and quality improving redesigned care processes across the entire patient population
Reduce growth in expendituresEstimated net savings for CY’s 2012 through 2014 = $510MEstimate 75-150 ACOs in first 3 years of the program
Shared savings model (one-sided model)Entry point for less experienced organizations in accepting financial riskAllows for time to gain experience, while under the FFS modelProposed that these organizations will transition to the two-sided model in their final year of their initial agreementShared savings/losses model (two-sided model)For those organizations experienced with managing population health and accepting riskGreater reward for those accepting riskOnly for MSS, Commercial ACOs come in a variety of flavors
Previous slide we talked about expectations, the NPRM gives us clearer direction on the requirements:
Technology such as CDS or a paper based methodology would likely sufficeTechnology such as portals, PHR’s, or paper based education as well as just engaging them in the processSuch reporting may include “developing a population health data management capability” or “implementing practice and physician level data capabilities with Point of service reminder systems” Measuring physician clinical and service performance, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.” They are looking for ACOs to coordinate care across the ENTIRE continuum. They give examples such as:Capability to use predictive modeling to anticipate likely care needsUtilization of case managers in primary care officesRemote monitoringTelehealthEstablishment and use of HIT, including EHR and HIE to enable the provision of a beneficiary’s summary of care record during transitions of care both within and outside of the ACO.
Transaction based vs. Value basedCommercial vs. CMS ACOShared SavingsTriple AimStructure and GovernanceLegal ConsiderationsFundamentally different than the HMOFee for Service paymentsLegislative Next StepsOngoing alignment between ACO and MUInvestments in HIT are expected and required
Traditionally non radiologists referred patients needing MRI to hospitals and other facilitiesThose factilities billed for the services, the referring physician did not bill anythingOver 1.5M episodes of care with 11,844 total orthodpedists and 6k neurologists- The 6% increase in spending was not only accounted for by MRI. Other services and procedures also accounted for the increase.Why? Financial? Convenience? Quality?Convenience: easier to make a referral, less paperwork, patient doesn’t have to go somewhere else. **However, much of the MRI useage did not occur on the day of the first visit but on a subsequent visit.
Patient/Caregiver Experience Timely care, appointments and information How well doctors communicate Helpful, courteous, respectful office staff Patient’s rating of doctor Shared decision making Health status/functional status
Care Coordination 30-day acute care readmission rates 30-day post discharge physician visit Medication reconciliation 60 days following hospital discharge Quality of preparation for care transition Ambulatory Sensitive Conditions Diabetes short-term complications Uncontrolled diabetes COPD CHF Dehydration Bacterial pneumonia Urinary tract infection Stage 1 Meaningful Use % ALL physicians % PCP % PCPs using clinical decision support % PCPs using eRx Patient registry use
Patient Safety Health Care Acquired Conditions: Foreign object retained after surgery Air embolism Blood incompatibility Stage II and IV pressure ulcers Falls and trauma Catheter-associated UTI Manifestations of poor glycemic control Central line associated blood stream infection Surgical site infection AHRQ Patient Safety indicators Accidental puncture or laceration Iatrogenic pneumothorax Post op DVT or PE Post op wound dihiscence Decubitus ulcer Selected infections due to medical care Post op hip fracture Post op sepsis CLABSI bundle
Data submission via claims or CDC National Healthcare Safety Network
Preventive Health Influenza immunization Pneumococcal vaccination Mammography screening within 24 months Colorectal screening Cholesterol management for patients with cardiovascular conditions Adult weight screening and follow-up Blood pressure measurement in patient with hypertension Tobacco use assessment and tobacco cessation intervention Depression screening
Data submission via GPRO data collection tool Measures based on PQRS, HITECH and NQF measures