Soraya Ghebleh - Use of Financial Incentives Paper
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Soraya Ghebleh - Use of Financial Incentives Paper Soraya Ghebleh - Use of Financial Incentives Paper Document Transcript

  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ Appropriate use of financial incentives designed to influence the clinical-decision making of providers ECS 154 Social and Behavioral Determinants of Health September 30th , 2012 Soraya Ghebleh
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ %$ Table of Contents Introduction....................................................................................................................... 1 Problem Statement and Magnitude ................................................................................ 1 Community of Interest ..................................................................................................... 2 Key Determinants ............................................................................................................. 3 Intervention ....................................................................................................................... 5 Conclusion ......................................................................................................................... 6 References.......................................................................................................................... 7 Appendix A. Socio-Ecological Conceptual Model........................................................ 10 Appendix B. Logic Model for Intervention .................................................................. 11 Appendix C. Example Incentive Programs for Small and Large Providers............. 12 $
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ %$ Introduction Clinical decisions of providers are one of the core factors influencing healthcare outcomes and are often directly tied to the financial incentives and reimbursement strategies established within a provider setting.1 The current state of healthcare in the United States is one of extremely high expenditure without a clear corresponding increase in quality.2 The Institute of Medicine’s six aims for improving quality in healthcare delivery fall under the categories of safety, effective, patient-centered, timely, efficient, and equitable healthcare.3 In order to accomplish these goals, financial incentives must be aligned with quality and performance measures and these measures must derive from meaningful data collection.3-6 Financial incentives for providers are an increasingly popular way to attempt to influence overall healthcare outcomes but the efficacy of these incentives must be continuously examined to prevent a further waste of resources and the use of direct financial incentives needs to be cautiously implemented based on evidence.7 Problem Statement and Magnitude Determining whether financial incentives for providers are an effective means of improving healthcare outcomes for patients and reducing inefficiencies within our healthcare system is a multi-faceted issue. The current system of fee-for-service delivery drives high healthcare costs because the incentive lies in performing more services but does not necessarily increase quality.8 The sheer magnitude of financial incentives that could potentially be introduced to various provider settings makes choosing the appropriate incentive or combination of incentives an onerous task.9 One difficulty lies in the fact that despite one successful implementation, the replication of similar results in other provider settings is not assured.10 Applicability of incentives that work in a large
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ =$ provider system may not translate to a solo or small group practice.5 Ensuring that smaller practices and individual providers are not lost in the transition towards accountable care organizations that involve high start-up capital and advanced healthcare technology is a concern for many practices around the country.6 Current methods of reimbursement include capitation, fee for service, pay-for- performance, and under accountable care organizations there is the shared savings model.9,11 Most financial incentives are contained within these reimbursement systems or they are used in addition to existing reimbursement schemes.12 Defining the parameters of success of a financial incentive program when there is no universal definition of what constitutes a successful intervention or an increased measure of quality can make determining effectiveness difficult and often unclear.13 There are also numerous players that may need to collaborate for successful incentive programs that include providers, insurance companies, beneficiaries, and government agencies and stakeholders.4 Community of Interest Providers are the target population for financial incentives aimed at improving quality and reducing cost. Healthcare systems in both developed and developing nations have had mixed results with use of financial incentives, indicating that there are potential implications with regard to the ethnicity and cultural background of the providers.14,15 There is also a distinction between providers that work in self-owned practices and small group practices compared to providers that are in a large provider network or a part of an accountable care organization.16,17
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ >$ Key Determinants Biology The biological makeup of providers varies widely and can directly affect how they respond to financial incentives to deliver care. Specific indicators include the age of the physician, where the physician went to school and trained, gender, religious background and upbringing, value system, ethnic background, socioeconomic background, and any personal biases that may exist.9,18 Behaviors Provider behaviors implicated in decision making include prescribing habits, personal work ethic and amount of time spent in preparation, numbers of tests ordered for patients, physician self-monitoring, personal spending habits, and the size of the workload the physician chooses to take on.19,20 The target income level of the provider will affect whether a financial incentive would be an important factor tying directly into family financial obligation.21,22 There is also an implicit assumption that all providers practice in the best interest of their patient.20 Social Environment The provider setting dictates the structure and the magnitude of incentive that will be given to the provider. Different settings include hospitals, clinics, ambulatory care centers, offices, and nursing homes.10 The organizational structure and culture of the provider setting can affect the success of incentives and the proportion of the group to which the incentive is relevant. If performance measurements set by the provider setting and incentives are aligned with these outcomes, a provider’s decision to participate may
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ '$ change with an increasingly congruent plan.23 The specialty of the provider is also important in whether incentives will be effective. Physical Environment The access of the provider to the tools necessary to improve quality is important. Providers practicing in rural or impoverished areas may have very different responses to incentives than providers practicing in urban or in higher income locations.24 Different geographic locations are often tied in with different patient populations who have different diseases and these are also factors providers react to when providing care.25 Policies and Interventions The structure of the incentive is crucial to provider participation.16 Government policy factors include government insurance reimbursements from Medicare and Medicaid. Provider adherence to clinical guidelines set by academic institutions and what the status quo of quality provision is among a provider community are both indicators of the likelihood of incentives working within that provider community.26 The introduction of the Patient Affordable Care Act will have huge implications for providers if the methods of reimbursement change and shared savings models begin to dominate the healthcare arena.27 Access to Quality Health Care The lack of reimbursements and the inability of many patients to pay their copayments and deductibles have led to an endemic increase in over-testing, over- prescribing, and over-diagnosing.28 Providers don’t necessarily need incentives to provide increased access to quality care but under current reimbursement schemes they have more of an incentive to increase quantity and this has increased the cost burden.29
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ &$ Intervention Financial incentives designed to change clinical behavior will not be successful in every setting and successful interventions will take into consideration certain factors before planning an incentive for providers.30 Financial incentives should be used in extremely defined settings for defined problems within defined populations where measurable results can be produced indicating movement towards a desired increase in quality.17,31,32 An advantage large provider settings have compared to small provider settings is the ability to assume more risk, higher capabilities for infrastructure and technology implementation, and a larger pool to measure performance improvement and quality metrics.4,25,33 This is important when evaluating whether a provider setting is able to participate in shared savings models.6 There are interventions, however, that can work in both small and large provider settings. (Refer to Appendix C) Examples of this are absolute threshold, directly measurable incentives like increased vaccinations, reduced repeat unnecessary lab tests, and increased cancer screening.20 Incentives of any kind should be explicitly described and known to providers and they should be aware of what entity is paying for the intervention.34 Determining short- term goals as compared to long-term goals is important when coming up with metrics of success for the incentive.21,35 Different metrics that should be considered for examination should include the provider population providing the data, the percentage of patients being targeted for the incentive, the expected overall effects of the incentive, and the type of feedback given.9,36-38 On the reverse side of financial incentives, financial risks and penalties may also serve to influence and change physician behavior.13 A large emphasis on financial incentives within a setting can potentially decrease intrinsic motivation when
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ ?$ amplified by organizational pressure.39 The ACO model of financial incentives under shared savings is an example of a financial incentive that ties cost reduction directly with quality improvement and shared savings but within ACO models the geographical region, technology capabilities, already-existing infrastructure, quality metrics, stakeholders, and provider organizational culture will determine whether an ACO model should be implemented or not.27,34,40,41 Conclusion $ Financial incentives are not going anywhere and will continue to be implemented in a variety of healthcare settings. In order for these incentives to be utilized properly, the healthcare community needs to understand that financial incentives and reimbursement strategies are provider and setting specific and implement incentives accordingly. $ $
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ @$ References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`#SL$75+35*-X$R*51$60.*)+30$P+:60-5$P(,*):D$./*+012(/<( %"12$%(#"+D&'"#(+"#"1+'%(P(E/2&'-3(a)5$=H%%I%?J'KL='bM=&%D$ !#"$ ;*-7<F3X$W/D$O00MO(3M#032*)0$^*,,$G06+*-$S$O0+5F30$a8$N+c(3$W+:60-5$ G08(367B$G0YF*3*-X$N(30$"1+-X07$U-$N0.*)+30$W1:7*)*+-$W+:60-5D$;"12$%( !<<1&+#3(=H%=I>%JbKL%b@@M%bZ>D$ !$"$ S36(F3$/#B$W*557$NNB$N+),0+-$GB$05$+,D$E10$0880)5$(8$0P,*)*5$8*-+-)*+,$ *-)0-5*207$(-$P1:7*)*+-$<01+2*(3D$!+'%&D"#(/<(C0$"+012(4"G&'&0"3( =HH%I%?%J%HKL%=?%D$ !%"$ W0+<(.:$AB$#1*6[1+.+$GB$TF*6<($#B$05$+,D$O*-+-)*+,$U-)0-5*207$S-.$ N0+7F3060-5$U6P3(20.$W1:7*)*+-7d$TF+,*5:$a8$"+30$U-$E10$W1*,*PP*-07D$ ;"12$%(!<<1&+#3$=H%%I>HJ'KL@@>M@Z%D$ !&"$ a,*203$SB$/3(R-$C4D$U-)0-5*2*e*-X$P3(8077*(-+,7$+-.$P+5*0-57L$+$)(-7*.03+5*(-$ *-$510$)(-505$(8$510$`-*50.$f*-X.(6$+-.$510$`-*50.$#5+507D$./*+012(/<(%"12$%( E/2&$&'#Q(E/2&'-(10G(21:3(O0<$=H%%I>?J%KL&bMZ@D$
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ Z$ !'"$ C00$E9B$/(510$SB$#500,0$;4D$9(R$;0*7*-X03$#53F)5F307$U57$W1:7*)*+-7d$ "(6P0-7+5*(-$E($#FPP(35$U6P3(2060-57$U-$TF+,*5:B$!88*)*0-):B$S-.$Q(,F60D$ ;"12$%(!<<1&+#3(=H%=I>%JbKL=H?ZM=H@>D$ !("$ 9*XX*-7$SB$#50R+35$fB$4+R7(-$fB$/())1*-($"D$!+3,:$C077(-7$O3(6$S))(F-5+<,0$ "+30$N(.0,7$U-$E10$W3*2+50$#0)5(3L$W+35-0371*P7$/05R00-$90+,51$W,+-7$S-.$ W3(2*.037D$;"12$%(!<<1&+#3(=H%%I>HJbKL%@%ZM%@=@D$ !)"$ N)4(-+,.$GB$9+33*7(-$#B$"10)[,+-.$f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g$G0+)5*(-7$O3(6$O3(-5,*-0$W1:7*)*+-7D$!7"+&'10(.(/<( 4"G(6*123(=HH?I=%J?KL>?@M>@'D$ #!"$ N+371+,,$NB$#6*51$WD$G0R+3.*-X$307F,57L$F7*-X$8*-+-)*+,$*-)0-5*207$5($*6P3(20$ YF+,*5:D$6*12&$-(P(#1<"$-(&0(%"12$%('1+"3(40)$=HH>I%=J?KL>b@M>bZD$ ##"$ N+371+,,$NB$9+33*7(-$#D$U5_7$+<(F5$6(30$51+-$6(-0:L$8*-+-)*+,$*-)0-5*207$+-.$ *-503-+,$6(5*2+5*(-D$6*12&$-(P(#1<"$-(&0(%"12$%('1+"3(O0<$=HH&I%'J%KL'M&D$ #$"$ /+-7+,$;B$^075$4AD$E10$S"a$P+3+.($*6P+)5*-X$P1:7*)*+-7D$?%"(./*+012(/<( 7"G&'12(E+1'$&'"(7101,"7"0$(8(4B43$=H%=I=@J?KL>Z&M>ZbD$ #%"$ O3*0.<03X$N^B$#+83+-$4;B$"(,5*-$fB$4307703$NB$#)1-0*.03$!"D$W+:*-X$O(3$ W038(36+-)0$U-$W3*6+3:$"+30L$W(50-5*+,$U6P+)5$a-$W3+)5*)07$S-.$4*7P+3*5*07D$ ;"12$%(!<<1&+#3(=H%HI=bJ&KLb=?Mb>=D$ #&"$ /(.0-10*603$EB$N+:$A9B$/030-7(-$GSB$"(FX1,+-$AD$"+-$6(-0:$<F:$YF+,*5:g$ W1:7*)*+-$307P(-70$5($P+:$8(3$P038(36+-)0D$C##*"(S+&"<(H5"0$"+(</+()$*G-&0,( ;"12$%()-#$"7(5%10,"I3(40)$=HH&J%H=KL%M'D$ #'"$ "(-3+.$4SB$W033:$CD$TF+,*5:M<+70.$8*-+-)*+,$*-)0-5*207$*-$10+,51$)+30L$)+-$R0$ *6P3(20$YF+,*5:$<:$P+:*-X$8(3$*5g$!00*12(+"D&":(/<(E*S2&'(%"12$%3( =HHbI>HL>&@M>@%D$ #("$ #1*0,.7$N"B$W+50,$W9B$N+--*-X$NB$#+)[7$CD$S$6(.0,$8(3$*-50X3+5*-X$ *-.0P0-.0-5$P1:7*)*+-7$*-5($+))(F-5+<,0$)+30$(3X+-*e+5*(-7D$;"12$%(1<<1&+#( HB+/N"'$(;/E"I3(A+-$=H%%I>HJ%KL%?%M%@=D$ #)"$ 90--*XM#)16*.5$9B$#0,50-$GB$^*070-$4D$9(R$P+:60-5$7:75067$+880)5$ P1:7*)*+-7_$P3(2*7*(-$<01+2*(F3MM+-$0P03*60-5+,$*-2075*X+5*(-D$.(/<(%"12$%( "'/03(=H%%I>HJ'KL?>@M?'?D$ #*"$ S203:$;B$#)1F,5e$AD$G0XF,+5*(-B$O*-+-)*+,$U-)0-5*207B$+-.$510$W3(.F)5*(-$(8$ TF+,*5:D$!7(.(/<(4"G(6*123(=HH@I==J'KL=?&M=@>D$ $+"$ #)(55$SB$#*20:$WB$S*5$aF+[3*6$4B$05$+,D$E10$0880)5$(8$8*-+-)*+,$*-)0-5*207$(-$510$ YF+,*5:$(8$10+,51$)+30$P3(2*.0.$<:$P3*6+3:$)+30$P1:7*)*+-7D$5/'%+10"( G1$1S1#"(/<(#-#$"71$&'(+"D&":#(HJ02&0"I3(=H%%JbKL"4HHZ'&%D$ $!"$ O,(.X30-$;B$!)),07$NWB$#10PP03.$#B$#)(55$SB$W+360,,*$!B$/0:03$OGD$S-$(2032*0R$ (8$302*0R7$02+,F+5*-X$510$0880)5*20-077$(8$8*-+-)*+,$*-)0-5*207$*-$)1+-X*-X$
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $ b$ 10+,51)+30$P3(8077*(-+,$<01+2*(F37$+-.$P+5*0-5$(F5)(607D$5/'%+10"(G1$1S1#"( /<(#-#$"71$&'(+"D&":#(HJ02&0"I3(=H%%J@KL"4HHb=&&D$ $#"$ VFX0-5$N!D$W+:60-5$308(36B$+))(F-5+<,0$)+30B$+-.$3*7[L$0+3,:$,077(-7$8(3$ P3(2*.037D$;"12$%'1+"(<&010'&12(7101,"7"0$(8(N/*+012(/<($%"(;"12$%'1+"( K&010'&12(4101,"7"0$(!##/'&1$&/03(=H%HI?'J%HKL>ZM'=D$ $$"$ C*0<036+-$#NB$/035[($AND$/F*,.*-X$G0XF,+5(3:$S-.$aP03+5*(-+,$O,0*<*,*5:$ U-5($S))(F-5+<,0$"+30$a3X+-*e+5*(-7$S-.$h#1+30.$#+2*-X7dD$;"12$%(!<<1&+#3( =H%%I>HJ%KL=>M>%D$ $%"$ 40Q(30$#B$"1+6P*(-$G^D$43*2*-X$W(PF,+5*(-$90+,51$E13(FX1$S))(F-5+<,0$ "+30$a3X+-*e+5*(-7D$;"12$%(!<<1&+#3(A+-F+3:$%B$=H%%$=H%%I>HJ%KL'%M&HD$ $&"$ /1+XR+5$A;B$a-.+50XF*MW+33+$#B$](F$f9B$05$+,D$N(5*2+5*(-$+-.$)(6P0-7+5*(-$ *-$+)+.06*)$3+.*(,(X:D$./*+012(/<($%"(!7"+&'10(5/22","(/<(F1G&/2/,-(8(.!5F3(AF,$ =HH'I%J@KL'b>M'b?D$ $'"$ /0,*)e+$!B$!205(2*57$ED$iO*-+-)*+,$*-)0-5*207$8(3$YF+,*5:$*6P3(2060-5jD$T","( 1+$&#(7"G&'&01"(8(*N(71,-1+(/+D/#&(%&+7/0G/3(N+:$=H%HI=HJ&KL>>%M>>ZD$ $("$ !*c[0-++3$OD$W+:$8(3$W038(36+-)0$*-$90+,51$"+30D$4"G&'12(51+"(F"#"1+'%(10G( F"D&":3$=H%=I?bJ>KL=&%M=@?D$ $)"$ "(66*5500$(-$G0.07*X-*-X$90+,51$U-7F3+-)0$W038(36+-)0$N0+7F307$WB$ W3(X3+67$WUD$B"+</+710'"(4"1#*+"7"0$8(!''"2"+1$&0,(C7E+/D"7"0$( HB1$%:1-#($/(6*12&$-(;"12$%(51+"()"+&"#IL$E10$V+5*(-+,$S)+.06*07$W3077I$ =HH?D$ $*"$ 4+2*07$9EB$C+6P0,$AD$E3F75$*-$P038(36+-)0$*-.*)+5(37g$6*12&$-(&0(;"12$%(51+"3( %bbZI@J>KL%&bM%?=D$ %+"$ C0R*7$QSB$C+37(-$/fB$N)",F3X$S/B$/(7R0,,$G;B$O*7103$!#D$E10$W3(6*70$S-.$ W03*,$a8$S))(F-5+<,0$"+30$O(3$QF,-03+<,0$W(PF,+5*(-7L$S$O3+60R(3[$O(3$ a203)(6*-X$a<75+),07D$;"12$%(!<<1&+#3(SFXF75$%B$=H%=$=H%=I>%JZKL%@@@M%@Z&D$ %!"$ /+*,*5$NB$9FX107$"D$f0:$.07*X-$0,060-57$(8$71+30.M7+2*-X7$P+:60-5$ +33+-X060-57D$C##*"(S+&"<(H5/77/0:"12$%(K*0GI3(SFX$=H%%I=HL%M%?D$ , $ $ $
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $%H$ Appendix A. Socio-Ecological Conceptual Model $ $ $ S.+P50.$83(6L$N)C03(:$05$+,D$S-$0)(,(X*)+,$P037P0)5*20$(-$10+,51$P3(6(5*(-D$;"12$%(UG*'(R"%1D",!*))-%&J'KL$$&!.$((-,, /+1,X30-B$;B$^1*5010+.$ND$B/2&'&"#(10G(#$+1$",&"#($/(E+/7/$"(#/'&12("L*&$-(&0(%"12$%3(#5()[1(,6L$#5()[1(,6$OF5F30$#5F.*07D$ %bb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
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $%%$ Appendix B. Logic Model for Intervention $ $ $ $ !"#$%&'()*+,"&-.&/),#.0)$1"/&+)-.)-)"&.1%0)#2)!"#3*/&"),%*+*,-%)/&,*.*#+)'-4*+5) Resources 1. Medicare/ Medicaid Data (Dartmouth Atlas) 2. Provider Setting (ex: Geisinger System, Accountable Care Organizations) 3. Insurance Companies 4. State Government Initiatives/ Funding Outputs 1. # Rate Reduction of unnecessary tests 2. # Meetings between administrators and providers 3. # Performance Reports and # Data Metrics Shared 4. #Incentivized Clinical Actions (ex childhood vaccinations, cancer screening tests, STD tests, physical examinations, flu shots) Outcomes 1. Reduced excess expenditure and waste in provider setting (ex reduced # of repeat lab/imaging tests ordered) 2. Financial incentives aligned with quality measures agreed upon by providers and administration as a result of increased communication 3. Faster, more streamlined reimbursement for providers in conjunction with a reduction in unnecessary payment for extra tests 4. Increased amount of specific, commonly required/necessary services provided more frequently and enthusiastically by providers Logic Model: Financial Incentives meant to change Provider Behavior resulting in improved quality and reduced cost Assumptions: Providers want best possible outcomes for patients while being reward financially for delivering high quality healthcare External Factors: Payment methods to providers affects their clinical decision making; changes in decision making may lead to decreased cost and increased quality .6789:());4)4:<<6==)267>?@A6>B)) %6=C9)'6?:<)/:D:<6EF:>G)57C?:B) Activities 1. Examining high cost tests and comparing results to increased health value 2. Physician engagement in planning relevant payment strategies and looking at implementing incentive programs in environments proven to work 3. Improving feedback loop and dialogue between providers and insurance companies for effective reimbursement 4. Choosing specific goals to be incentivized for providers in alignment with government health goals Impact 1. Overall cost burden of healthcare system reduced 2. Integration between providers and administration directed at successful incentive programs 3. Shift from over- utilization of resources and resistance of reimbursement from insurance companies to alignment of goals between providers and insurance companies 4. Improved local and state health outcomes for the patient population of provider’s receiving incentives
  • !"#$%&'$#()*+,$+-.$/01+2*(3+,$405036*-+-57$(8$90+,51$ #(3+:+$;10<,01$ $ $%=$ Appendix C. Example Incentive Programs for Small and Large Providers $ , 01233, 456789:5, 0:;;8<=$, >25=:, 456789:5, 0:;;8<=, ?<@:<;87:A, 456=521, /:B@58C;86<, DE233:<=:B, F96C;G, HAI, F96C;G,, HAI, TF+,*5:$ /(-F707$ /(-F7$X*20-$<+70.$(-$ +)1*02*-X$+$ P038(36+-)0$ 60+7F3060-5D$ 405036*-*-X$R105103$ <(-F707$+30$308,0)5*20$(8$ +)5F+,$P038(36+-)0$+-.$ YF+,*5:$*6P3(2060-57B$ W3(2*.03$30c0)5*(-$(8$<0*-X$ .*88030-5*+,,:$<+70.$(-$ P038(36+-)0$ k$ k$ /F-.,0.$ W+:60-5$ CMS would link payments for multiple services patients receive during an episode of care. "(6P,0$6(.0,B$<F*,.7$(-$ +,30+.:$0*75*-X$800M8(3M 7032*)0$6051(.7$51+5$+30-d5$ -0)077+3*,:$0880)5*20B$ 50)1-*)+,$*77F07$ V$ k$ W*(-003$S"a$ N(.0,$$ ;3(FP$(8$P3(2*.037$ +-.$7FPP,*037$(8$ 7032*)07$51+5$R*,,$ P3(2*.0$)+30$5($ *6P3(20$YF+,*5:$+-.$ 30.F)0$)(75B$R*51$ 30.F)5*(-$(8$)(75$ P3(2*.*-X$71+30.$ 7+2*-X7D$$$$ C+3X0$P3(2*.03$7055*-X$ -00.0.B$753(-X$ *-83+753F)5F30B$*-+<*,*5:$5($ +77F60$,+3X0$+6(F-57$(8$ 3*7[B$0P0-7*20$10+,51)+30$ 50)1-(,(X:$-00.0.$8(3$ *6P,060-5+5*(-B$0+7:$ *-50X3+5*(-$(8$P3(2*.037B$ (850-$30YF*307$+-$+,30+.:$ 0*75*-X$(3X+-*e+5*(-+,$ 753F)5F30$+-.$,+3X0$-05R(3[$ 8(3$0+7:$*6P,060-5+5*(-$ V$ k$ S.2+-)0.$ W+:60-5$ S"a$N(.0,$ Selected organizations will receive an advance on the shared savings they are expected to earn. Participating ACOs will receive three types of payments. N+:$<0$+$6(30$+PP,*)+<,0$ 6(.0,$8(3$76+,,03$ (3X+-*e+5*(-7$(3$51(70$51+5$ .($-(5$1+20$510$75+35MFP$ )+P*5+,$5($*660.*+50,:$ 53+-7*5*(-$*-5($+$)(6P,050$ S"a$6(.0,D$#5*,,$R(F,.$-(5$ 30)(660-.$8(3$+$76+,,$ P3+)5*)0$+5$51*7$P(*-5$*-$ .020,(P60-5$(8$S"a$6(.0,D$$ V$ k$ O00$8(3$ #032*)0$ ;*2*-X$+$P+:60-5$*-$ 0)1+-X0$8(3$+$7032*)0$ 30-.030.D$ W3(2*.07$*-)0-5*207$8(3$ (203F70$(8$7032*)07$+-.$8+*,7$ 5($*6P(70$7:7506+5*)$ P0-+,5*07$8(3$6*7F70$(3$ F-.03F70$(8$60.*)+,$)+30$ k$ k$ W+:$8(3$ W038(36+-)0$ W+:*-X$7P0)*8*)+,,:$8(3$ P038(36+-)0$ *6P3(2060-5$<+70.$ (-$.08*-0.$YF+,*5:$ 60+7F307$ N053*)7$F70.$5($60+7F30$ P038(36+-)0$6+:$-(5$ )(3307P(-.$5($+-$+)5F+,$ *-)30+70$*-$YF+,*5:D$$ k$ k$ 4+5+$#(F3)0L$"0-503$8(3$N0.*)+*.$l$N0.*)+30$U--(2+5*(-B$S))0770.$#0P506<03B$=ZB$=H%=D$ 155PLmmRRRD+)+.+6:10+,51D(3Xm8*,07m-1)P*m*-)0-5*207DP.8$