source retrieved from www.democrats.senate.gov/reform.com
Source retrieved from www.integratedhealthcareassociation.org
Table of Contents• PART I: Introduction, History, ACO Stake holders, Core principles for all ACOs, CMS Announcement you-tube clip (Anthony Harding)• PART II: Overview of ACO and Key Elements of ACO/Health Reform• (Jolly Patel)• PART IV: The ACO - Immediate Benefits for Delaware• (Anthony Mbirwe)• PART V: Conclusion• (Jitka Gruntova)
Introduction An accountable care organization The ACO is accountable to the (ACO) is a type of payment and patients and the third-party payer delivery reform model that seeks to for the quality, appropriateness, and tie provider reimbursements to efficiency of the health care quality metrics and reductions in provided. the total cost of care for an assigned According to the Centers for population of patients. Medicare and Medicaid Services A group of coordinated health care (CMS), an ACO is "an organization providers form an ACO, which then of health care providers that agrees provides care to a group of patients. to be accountable for the quality, The ACO may use a range of cost, and overall care of Medicare payment models (capitation, fee- beneficiaries who are enrolled in for-service with asymmetric or the traditional fee-for-service symmetric shared savings, etc.). program who are assigned to it.
ACO Stakeholders Providers-ACOs are comprised mostly of hospitals, physicians, and other healthcare professionals. Depending on the level of integration and size of an ACO, providers may also include health departments, social security departments, safety net clinics, and home care services. Payers- The federal government, in the form of Medicare, will be the primary payer of an ACO. Other payers include private insurances, or employer-purchased insurance. Patients- An ACO‟s patient population will primarily consist of Medicare beneficiaries. In larger and more integrated ACOs, the patient population may also include those who are homeless and uninsured.
History The term “Accountable Care Organization” Like the HMO, the ACO is “an entity that was first used by Elliott Fisher – Director will be „held accountable‟ for providing of the Center for Health Policy Research at comprehensive health services to a Dartmouth Medical School population.“ In 2006 during a discussion at a public The ACO-model builds on the Medicare meeting of the Medicare Payment Advisory Physician Group Practice Demonstration Commission. and the Medicare Health Care Quality The term quickly became Demonstration, established by the 2003 widespread, reaching its pinnacle in 2009 Medicare Prescription Drug, Improvement, when it was included in the Patient and Modernization Act. Protection and Affordability Care Act. Kaiser Permanente and HealthCare Although the term ACO was not coined Partners Medical Group are two notable until 2006, it bears resemblance to the examples of successful ACO prototypes. definition of the Health Maintenance However, a recent study by the Medical Organization (HMO), which rose to Group Management Association (MGMA) prominence in the 1970s. has shown that the implementation of ACOs is one of the toughest challenges facing the MGMA members today
CMS Announces Accountable Care Organization Rule http://youtu.be/K1OwHo3kV1o
What Is An Accountable Care Organization (ACO)? http://youtu.be/ULy5vjcGuDc Consists of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth May involve a variety of provider configurations, ranging from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians such as independent practice associations Has a strong base of primary care, although hospitals are encouraged to participate, because improving hospital care is essential to success
ACOs In PerspectiveThink of it like buying a television... A TV manufacturer such as Sony may contract with manysuppliers to build a TV – like a Sony, an ACO would bringtogether the different component parts of care for thepatient (primary care, specialists, hospitals, home healthcare, etc.) and ensure that all of the parts work well togetherThe problem today is that patients are getting each part oftheir health care separately – they are buying individualcircuit boards, not a whole TV
How Does It Differ From HMOs? The principle difference between HMOs and ACOs is their size HMOs, like most insurance companies, generally have enrollees in the hundreds of thousands compared with as few as 5,000 HMOs function like insurance companies (they bear 100 percent of the risk that the premiums they charge will not be enough to cover all necessary services for their enrollees) while ACOs will bear little or no insurance risk in their first few years
Key Concepts The key concepts for ACOs are “continuum of the care” and “quality of the care” ACOs in the future will see incentives for providers who keep costs down and still manage to meet specific quality benchmarks, concentrating on prevention of chronic diseases and efficient disease management Keeping the costs of hospitalizations under control and then providing quality home healthcare to patients is essential to success
ACOs & The PPACA The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Obama on March 23,2010 The PPACA’s intent is to ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs
PPACA Titles I - IIIThe Patient Protection and Affordable Care Act containsnine titles, each addressing an important component ofreform:I. Quality, affordable health care for all AmericansII. The role of public programsIII. Improving the quality and efficiency of health care
PPACA Titles IV - IXIV. Prevention of chronic disease and improving public healthV. Health care workforceVI. Transparency and program integrityVII. Improving access to medical therapiesVIII. Community living assistance services and supportsIX. Revenue provisions
Title IIIImproving the Quality and Efficiency of Health Care The PPACA will encourage development of new Patient Care Models starting with a new Center for Medicare & Medicaid Innovation to be established within the Centers for Medicare and Medicaid Services
Medicare & Medicaid Innovation This new Center for Medicare & Medicaid Innovation will have the responsibility of research, development, testing and expanding innovative payment and delivery arrangements ACOs that take responsibility for cost and quality received by patients will receive a share of savings they achieve for Medicare
Requirements For ACO Status1. A willingness to become accountable for the quality, cost, and overall care of the Medicare beneficiaries it treats2. Entrance into an agreement with the Secretary of Health and Human Services (HHS) to participate in the program for not less than 3 years3. A formal legal structure that allows the entity to receive & distribute payments
Requirements Continued4. The inclusion of primary care professionals that are sufficient for the number of Medicare beneficiaries assigned to the ACO5. Provision to the Secretary of information regarding the professionals who participate in the ACO and implementation of quality and other reporting requirements
Requirements Continued6. A leadership and management structure that includes clinical and administrative systems7. Defined processes that promote evidence-based medicine and patient engagement, reporting on quality and cost measures, and care coordination8. Demonstration that the organization meets patient- centered criteria
More About ACOs The ACO initiative was scheduled to launch in January 2012 Right now, a main source of revenue for healthcare organizations comes from the tests and procedures performed on patients in the current fee-for-service payment system, but after the creation of ACOs, organizations and providers will get paid for saving more while still providing quality healthcare to the patients - they will get paid for keeping patients healthy and out of the hospital
Financial Savings Associated With ACOs The Congressional Budget Office estimates that ACOs could save Medicare at least $4.9 billion through 2019 – less than one percent of Medicare spending during that period, but if the program is successful it can be expanded by the Secretary of Health and Human Services
Cost Considerations For The ACO Predominately large hospital systems and big physician groups are pursuing the ACO concept due to the large investment required in healthcare IT and infrastructure ACOs are designed to encourage consolidation among hospitals and doctors which has also drawn anti-trust scrutiny If an ACO is not able to save money, it would be stuck with the costs of investments made to improve care, such as adding new nurse care managers, but would still get to keep the standard Medicare fees
Who Is In Charge Of The ACO? It’s flexible – can be hospitals, doctors, or even insurers Some regions of the country already have large multi- specialty physician groups that may become an ACO on their own, likely by networking with neighboring hospitals In other regions, large hospital systems are buying physician practices with the goal of becoming ACOs that directly employ the majority of their providers (because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment required by an ACO)
What Does This Mean For You, The Patient? http://youtu.be/Xlq2XJ6J76g Patients may not even know that they are part of an ACO Doctors will want to refer patients to hospitals and specialists within the ACO network, however patients will still be free to see doctors of their choice outside the network Because ACOs will be under pressure to provide high quality care in order to receive financial benefits, patients should ultimately receive better care
The ACO - Immediate Benefits for DelawareSupport for seniors Last year, roughly 11,900 Medicare beneficiaries in Delaware hit the donut hole, or gap in Medicare Part D drug coverage, and received no additional help to defray the cost of their prescription drugs. By August last year, 2,983 of seniors in Delaware had received their $250 tax free rebate for hitting the donut hole The new law continues to provide additional discounts for seniors on Medicare in the years ahead and closes the donut hole by 2020Free preventive services for seniors All 140,000 of Medicare enrollees in Delaware will get preventive services, like colorectal cancer screenings, mammograms, and an annual wellness visit without copayments, coinsurance, or deductibles.
The ACO - Immediate Benefits for DelawareCoverage expansions $13 million from federal government will be available for Delaware State beginning July 1st to provide coverage for uninsured residents with pre-existing medical conditions through a new Pre-Existing Condition Insurance Plan program, funded entirely by the Federal government This program is a transition to 2014 when Americans will have access to affordable coverage options in the new health insurance system and insurance companies will be prohibited from denying coverage to Americans with pre-existing conditions.Small business tax credits About 14,000 small businesses in Delaware will be eligible for the new small business tax credit that makes it easier for businesses to provide coverage to their workers and makes premiums more affordable. Small businesses pay, on average, 18 percent more than large businesses for the same coverage and health insurance premiums have gone up three times faster than wages in the past 10 years.
The ACO - Immediate Benefits for DelawareExtending coverage to young adults When families renew or purchase insurance on or after September 23, 2010, plans that offer coverage to children on their parents‟ policy must allow children to remain on their parents‟ policy until they turn 26, unless the adult child has another offer of job-based coverage in some casesHealth coverage for early retirees An estimated 16,000 people from Delaware retired before they were eligible for Medicare and have health coverage through their former employers. Unfortunately, the numbers of firms that provide health coverage to their retirees have decreased over time. This year, a $5 billion temporary early retiree reinsurance program will help stabilize early retiree coverage and help ensure that firms continue to provide health coverage to their early retirees. Companies, unions, and State and local governments are eligible for these benefits
The ACO - Immediate Benefits for DelawareImproved Access to Care Patients‟ choice of doctors will be protected by allowing plan members in new plans to pick any participating primary care provider, prohibiting insurers from requiring prior authorization before a woman sees an ob- gyn, and ensuring access to emergency care.More doctors where people need them Beginning October 1, 2010, the Act will provide funding for the National Health Service Corps i.e. $1.5 billion over five years for scholarships and loan repayments for doctors, nurses and other health care providers who work in areas with a shortage of health professionals. And the Affordable Care Act invested $250 million dollars this year in programs that will boost the supply of primary care providers in this country – by creating new residency slots in primary care and supporting training for nurses and physician’s assistants. This will help the 14% of Delaware’s population who live in an underserved area
ACO’s- Summary ACO’s = health care organizations and related set of providers - primary care physicians, specialists, and hospitals that are accountable for the cost and quality of care delivered to a defined population. The goal of the ACO’s is to deliver coordinated and efficient care. ACO’s that achieve quality and cost targets will receive some sort of financial bonus, and, those that fail will be subject to a financial penalty
Concept of ACO’s ACO’s make the people and organizations that actually provide care accountable for the quality and the cost of that care. Previous health reform initiatives involved insurers and made them ultimately accountable.
The positive side of ACO’s Beneficiaries/patients will be able to go anywhere for care and will be able to use any physician. Patients will be able to enroll for lower premiums. New programs will be available and some programs will be expanded. For example, some services like screenings and vaccinations will become free. There will be new rules. For example, lifetime limits on health coverage will be gone. Insurers will be limited in how they spend premium dollars and they will no longer be able to turn people down or charge them more if theyre sick. Some small businesses will get tax breaks to help them pay for health insurance for their workers. By 2019, 32 million of American citizens who don‟t have health insurance will have it.
Negative side of ACO’s ACO‟s will cost 938 billion dollars over the next ten years, according to the Congressional Budget Office. A lot of the savings will come from health care providers and insurers in the Medicare program. The fees the government pays to hospitals under Medicare won‟t be allowed to rise as fast as they have been. Insurance companies that provide services to people on Medicare will be paid less. A terrible business deal for providers. In order to get any shared savings, they will have to spend millions on consulting, systems, care managers and IT staff, give up a dollar in immediately reduced income, and maybe, if they check all the boxes right, get 50 or 60 cents back in 18 months. Further, some taxes will go up too. For example, people with high earnings will pay higher Medicare taxes. There will be new taxes on insurers and businesses who offer high-end benefit plans, and on companies that make medical devices and drugs.
Do you like the new health care law, hate it, still don’t know? Any Questions?