The document discusses how accountable care organizations (ACOs) help achieve the vision of health care reform under the Affordable Care Act. ACOs aim to clarify health care goals, foster care coordination and accountability, and align payment incentives with quality care. Early evidence shows ACOs in Medicare programs and private sector initiatives have improved quality measures and reduced costs. The document notes ACOs are one part of broader reform efforts through the Center for Medicare and Medicaid Innovation to test new payment and delivery models beyond ACOs alone.
Accountable Care Organizations: Overview and the Role of Information TechnologyDave Shiple
This document provides an overview of Accountable Care Organizations (ACOs) and the role of information technology in ACOs. It describes the key features and goals of the Medicare Shared Savings Program for ACOs, including quality reporting requirements and the role of health information technology (HIT) in enabling care coordination, population health management, and sharing of cost savings. The document also presents potential delivery models, governance structures, and an IT reference model for ACOs.
February 9, 2012
These slides are designed for Post-Acute Care (PAC) providers seeking additional information about how Model 3 works and a better understanding of the opportunities for PAC providers within the Bundled Payment for Care Improvement (BPCI) initiative to achieve better care, better health and lower costs for their patients through care redesign.
More at: http://innovations.cms.gov/resources/Bundled-Payments-Model-3-Deep-Dive.html
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CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This was the second event in a two-part webinar series on the Primary Care First Seriously Ill Population (SIP) payment model option. During this webinar, the Primary Care First Model Options team reviewed additional details about the SIP payment model option. This webinar built upon what was discussed during the first SIP webinar held on July 24, 2019 and provided an opportunity for attendees to submit live questions.
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CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document summarizes a presentation on managed care contracting strategies for physician practices. The presentation covers: 1) Payer goals and how physician network participation impacts practices, 2) How patient steering works between payers, hospitals, and practices, and 3) Strategies practices can use to negotiate contracts and align with other providers. It discusses factors that influence referrals and revenues and challenges practices currently face in contracting with payers.
The Direct Contracting Model Options team hosted a webinar on January 15, 2020 to provide an overview of the Direct Contracting Model's payment methodology. During the session, the Direct Contracting model team presented key aspects of the Direct Contracting financial model, such as its risk-sharing options and risk mitigation strategies, as well as its capitation and other advanced payment alternatives. The forum also provided an opportunity for potential applicants to ask the team questions regarding these topics and other topics related to the model application.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held a Comprehensive Care for Joint Replacement Model webinar on proposed rule changes to the model on September 7, 2016.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Centers for Medicare and Medicaid Services (CMS) State Innovation Models Initiative provides funding to support states in developing and testing innovative healthcare payment and service delivery models. States can apply for one of two types of awards - planning grants of $1-3 million to support model design or testing grants of $20-60 million over 3 years to implement models. The goal is to engage multiple payers and stakeholders to transform healthcare delivery from a volume-based system to one that rewards better health outcomes at lower cost. States must demonstrate how their models will achieve improved health, care experience and affordability through payment and delivery system reform.
Accountable Care Organizations: Overview and the Role of Information TechnologyDave Shiple
This document provides an overview of Accountable Care Organizations (ACOs) and the role of information technology in ACOs. It describes the key features and goals of the Medicare Shared Savings Program for ACOs, including quality reporting requirements and the role of health information technology (HIT) in enabling care coordination, population health management, and sharing of cost savings. The document also presents potential delivery models, governance structures, and an IT reference model for ACOs.
February 9, 2012
These slides are designed for Post-Acute Care (PAC) providers seeking additional information about how Model 3 works and a better understanding of the opportunities for PAC providers within the Bundled Payment for Care Improvement (BPCI) initiative to achieve better care, better health and lower costs for their patients through care redesign.
More at: http://innovations.cms.gov/resources/Bundled-Payments-Model-3-Deep-Dive.html
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This was the second event in a two-part webinar series on the Primary Care First Seriously Ill Population (SIP) payment model option. During this webinar, the Primary Care First Model Options team reviewed additional details about the SIP payment model option. This webinar built upon what was discussed during the first SIP webinar held on July 24, 2019 and provided an opportunity for attendees to submit live questions.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document summarizes a presentation on managed care contracting strategies for physician practices. The presentation covers: 1) Payer goals and how physician network participation impacts practices, 2) How patient steering works between payers, hospitals, and practices, and 3) Strategies practices can use to negotiate contracts and align with other providers. It discusses factors that influence referrals and revenues and challenges practices currently face in contracting with payers.
The Direct Contracting Model Options team hosted a webinar on January 15, 2020 to provide an overview of the Direct Contracting Model's payment methodology. During the session, the Direct Contracting model team presented key aspects of the Direct Contracting financial model, such as its risk-sharing options and risk mitigation strategies, as well as its capitation and other advanced payment alternatives. The forum also provided an opportunity for potential applicants to ask the team questions regarding these topics and other topics related to the model application.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held a Comprehensive Care for Joint Replacement Model webinar on proposed rule changes to the model on September 7, 2016.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Centers for Medicare and Medicaid Services (CMS) State Innovation Models Initiative provides funding to support states in developing and testing innovative healthcare payment and service delivery models. States can apply for one of two types of awards - planning grants of $1-3 million to support model design or testing grants of $20-60 million over 3 years to implement models. The goal is to engage multiple payers and stakeholders to transform healthcare delivery from a volume-based system to one that rewards better health outcomes at lower cost. States must demonstrate how their models will achieve improved health, care experience and affordability through payment and delivery system reform.
The document discusses three CMS innovation models for 2021:
1) The Part D Senior Savings Model offers $35 copays for insulin to lower costs.
2) The Part D Payment Modernization Model tests lower drug costs and improved quality through payment incentives.
3) The Value-Based Insurance Design Model tests benefit flexibilities in Medicare Advantage, such as reduced cost sharing and rebates, to improve care.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering the application process for the 2017 Next Generation Accountable Care Organization Model on Tuesday, March 8, 2016 from 4:00 - 5:00pm EST.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Primary Care First (PCF) Model Options team hosted a series of four informational webinars about the PCF Model Options. Topics discussed included the model options' aims, requirements, benefits of participation, and application next steps. Attendees had the opportunity to submit questions to the model options team during each of the webinars. Each of the webinars covered the same information.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This webinar will highlight key areas from the document discussing what a strong application to the BPCI initiative should include. We encourage you to review the Models 2-4 application questions and the new Application Guidance document posted on the Bundled Payments for Care Improvement webpage, prior to this webinar.
More at: http://www.innovations.cms.gov/resources/Bundled-Payments-Application-Guidance.html
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
In follow-up to the March 10, 2015 announcement of the Next Generation Accountable Care Organization (ACO) Model of payment and care delivery, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted the third in a series of open door forums on March 31, 2015 focusing on financial methodology and related issues.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
1) The document summarizes a policy brief about accountable care organizations (ACOs) and the key issues in designing them.
2) An ACO aims to deliver coordinated, efficient care to a defined population by holding local healthcare providers accountable for quality and costs. It would receive bonuses for meeting targets but penalties for failing.
3) There are open questions about how to design ACs, including what types of providers must participate, how patients will be involved, and what payment methods should be used. The brief discusses these issues and implementation challenges.
The CMS Innovation Center offered a kickoff webinar event for the Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model on Tuesday, May 31, 2016 from 4:00–5 p.m. EDT. This webinar focused on model objectives, terms of the award, eligibility criteria, changes from the first public solicitation and important deadlines. A 20 minute question and answer period followed the presentation.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This recorded Accountable Health Communities Model webinar provides an overview of the learning system and implementation plan guide.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center hosted a Beneficiary Engagement and Incentives: Direct Decision Support (DDS) Model webinar regarding the model overview and Letter of Intent (LOI) process on Thursday, January 12, 2017 from 2:00 - 3:00 p.m. EST. At this event, attendees learned more about the DDS model, eligibility criteria, and LOI requirements.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Center for Medicare & Medicaid Innovation hosted an Open Door Forum (ODF) to allow dialysis facilities, nephrologists, other Medicare providers of services, suppliers, and other interested parties to ask questions on the revisions to the Request for Application (RFA) for the Comprehensive End Stage Renal Disease (ESRD) Care Initiative that was released on April 15, 2014.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview of three models being offered by the Center for Medicare and Medicaid Innovation (CMMI): Primary Care First, Direct Contracting, and Kidney Care Choices. It summarizes the presentation for a cross-model office hours session on these three models, including brief descriptions of each model's goals, payment structures, eligibility criteria, and timelines. The document also lists the presenters and includes polls for the audience.
Literature review: Results-based Financing in Maternal and Neonatal Health CareNewGHPC
This presentation was held in the context of a discussion, led by GIZ, on Results-based Health Financing in low- and middle-income countries.
To join the discussion go to www.german-practice-collection.org/en/discussions/gdcs-position-regarding-rbf-in-health and tweet via #HealthRBF.
As part of a broader partnership, CMMI, the Office of the Assistant Secretary for Health (OASH) and the Administration for Community Living (ACL) are jointly sponsoring a webinar titled, Unleashing the Capabilities of MAOs to Deliver Health Innovation for Older Adults in Underserved Settings on October 7 from 2:30-4:00 PM ET to highlight the emerging, numerous opportunities for MAOs to support beneficiaries in more fully meeting their care needs and goals through novel approaches and services enabled by technology.
The webinar will provide an overview of the data supporting these opportunities and will include a panel of three speakers from payer organizations, each of whom will provide an overview of their experience and results in innovating in the use of technology to address unmet enrollee health needs. Panelists include Mona Siddiqui MD, MPH, Senior Vice President for Enterprise Clinical Strategy and Quality at Humana, who will discuss Humana’s approach to the use of data and predictive modeling to proactively engage and provide care for the highest risk and most vulnerable populations; John Wiecha, Medical Director, Senior Products Division at Point32Health, representing the newly combined organizations of Harvard Pilgrim Health Care and Tufts Health Plan will provide an overview of a recent pilot project to improve dementia care through a digital caregiver support program; and Caesar A. DeLeo, MD, MHSA Vice President & Executive Medical Director Strategic Initiatives, Highmark Health Enterprise Clinical Organization, Highmark BCBS who will discuss Highmark’s experience with telemedicine to approach substance use disorders during the pandemic and results from a five-year data driven program addressing appropriate opiate prescribing through profiling and academic detailing.
The webinar offers attendees the opportunity to gain a better understanding of the evidence and potential of several technology-enabled services in improving access, quality and outcomes of care, including, importantly, for underserved populations and will provide MAOs with insights more broadly on the challenges and solutions in design, implementation and evaluation of innovative and technology-enabled service. MAOs that are considering such innovations who may wish to target the use of technology-enabled and/or other services based on chronic illness and/or Low-Income Subsidy (LIS) status through the VBID Model are encouraged to attend.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Next Generation ACO Model team hosted an open door forum on Tuesday, January 31, 2017. During this open door forum Model team members provided an overview of the Model, along with information pertaining to the Letter of Intent (LOI).
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held the second in a series of webinar events for the Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model on Wednesday, June 8, 2016 from 12:00p.m. – 1:30p.m. EDT. This webinar consisted of a panel discussion focusing on learning from past ESCO participants on what it takes to become a successful applicant and successful ESCO.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
In follow-up to the March 10, 2015 announcement of the Next Generation Accountable Care Organization (ACO) Model of payment and care delivery, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted a repeat of the first open door forum in a series focusing on various aspects of the Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document provides an overview of the Part D Senior Savings Model proposed by CMS Innovation Center. The model aims to lower out-of-pocket costs for insulin by establishing a stable $35 copay for eligible insulins through the deductible, initial coverage, and coverage gap phases of Part D plans. The model would be voluntary for manufacturers, Part D plans, and beneficiaries. It also outlines the application process and timelines for manufacturers and Part D plans to participate in the 2021 plan year.
The Next Generation ACO Model team hosted an open door forum on Tuesday, March 28, 2017. The Next Generation Model features three payment rule waivers, referred to as benefit enhancements. This open door forum provided an overview of the Model’s three benefit enhancements.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held the fourth in a series of webinars for potential applicants interested in applying to Health Care Innovation Awards Round Two. The webinar held on Thursday, June 20, 2013 from 1:00–2:00pm EDT, focused on how to achieve lower costs through improvement. This webinar also reviewed the components of the Financial Plan.
- - -
CMS Innovations
http://innovations.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document provides information about Accountable Care Organizations (ACOs) and the Medicare Shared Savings Program proposed by CMS. It explains that ACOs allow groups of healthcare providers to coordinate care for Medicare patients, with the goals of improving quality of care and reducing costs. Providers can form or join ACOs to participate in the program. ACOs will be evaluated on quality measures and their ability to lower healthcare spending compared to spending benchmarks. ACOs that meet quality standards and reduce costs below their benchmark can earn a share of the savings, with larger rewards available to ACOs that take on two-sided risk models involving potential loss sharing as well.
This document provides an overview of accountable care organizations (ACOs). It discusses that ACOs aim to improve care management, limit unnecessary expenditures, and provide patient freedom of choice while making providers financially accountable. The document outlines the principles of ACOs, their relationship to the Patient Protection and Affordable Care Act, payment models, quality measures, stakeholders, and challenges of implementing ACOs.
The document discusses three CMS innovation models for 2021:
1) The Part D Senior Savings Model offers $35 copays for insulin to lower costs.
2) The Part D Payment Modernization Model tests lower drug costs and improved quality through payment incentives.
3) The Value-Based Insurance Design Model tests benefit flexibilities in Medicare Advantage, such as reduced cost sharing and rebates, to improve care.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering the application process for the 2017 Next Generation Accountable Care Organization Model on Tuesday, March 8, 2016 from 4:00 - 5:00pm EST.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Primary Care First (PCF) Model Options team hosted a series of four informational webinars about the PCF Model Options. Topics discussed included the model options' aims, requirements, benefits of participation, and application next steps. Attendees had the opportunity to submit questions to the model options team during each of the webinars. Each of the webinars covered the same information.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This webinar will highlight key areas from the document discussing what a strong application to the BPCI initiative should include. We encourage you to review the Models 2-4 application questions and the new Application Guidance document posted on the Bundled Payments for Care Improvement webpage, prior to this webinar.
More at: http://www.innovations.cms.gov/resources/Bundled-Payments-Application-Guidance.html
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
In follow-up to the March 10, 2015 announcement of the Next Generation Accountable Care Organization (ACO) Model of payment and care delivery, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted the third in a series of open door forums on March 31, 2015 focusing on financial methodology and related issues.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
1) The document summarizes a policy brief about accountable care organizations (ACOs) and the key issues in designing them.
2) An ACO aims to deliver coordinated, efficient care to a defined population by holding local healthcare providers accountable for quality and costs. It would receive bonuses for meeting targets but penalties for failing.
3) There are open questions about how to design ACs, including what types of providers must participate, how patients will be involved, and what payment methods should be used. The brief discusses these issues and implementation challenges.
The CMS Innovation Center offered a kickoff webinar event for the Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model on Tuesday, May 31, 2016 from 4:00–5 p.m. EDT. This webinar focused on model objectives, terms of the award, eligibility criteria, changes from the first public solicitation and important deadlines. A 20 minute question and answer period followed the presentation.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This recorded Accountable Health Communities Model webinar provides an overview of the learning system and implementation plan guide.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center hosted a Beneficiary Engagement and Incentives: Direct Decision Support (DDS) Model webinar regarding the model overview and Letter of Intent (LOI) process on Thursday, January 12, 2017 from 2:00 - 3:00 p.m. EST. At this event, attendees learned more about the DDS model, eligibility criteria, and LOI requirements.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Center for Medicare & Medicaid Innovation hosted an Open Door Forum (ODF) to allow dialysis facilities, nephrologists, other Medicare providers of services, suppliers, and other interested parties to ask questions on the revisions to the Request for Application (RFA) for the Comprehensive End Stage Renal Disease (ESRD) Care Initiative that was released on April 15, 2014.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview of three models being offered by the Center for Medicare and Medicaid Innovation (CMMI): Primary Care First, Direct Contracting, and Kidney Care Choices. It summarizes the presentation for a cross-model office hours session on these three models, including brief descriptions of each model's goals, payment structures, eligibility criteria, and timelines. The document also lists the presenters and includes polls for the audience.
Literature review: Results-based Financing in Maternal and Neonatal Health CareNewGHPC
This presentation was held in the context of a discussion, led by GIZ, on Results-based Health Financing in low- and middle-income countries.
To join the discussion go to www.german-practice-collection.org/en/discussions/gdcs-position-regarding-rbf-in-health and tweet via #HealthRBF.
As part of a broader partnership, CMMI, the Office of the Assistant Secretary for Health (OASH) and the Administration for Community Living (ACL) are jointly sponsoring a webinar titled, Unleashing the Capabilities of MAOs to Deliver Health Innovation for Older Adults in Underserved Settings on October 7 from 2:30-4:00 PM ET to highlight the emerging, numerous opportunities for MAOs to support beneficiaries in more fully meeting their care needs and goals through novel approaches and services enabled by technology.
The webinar will provide an overview of the data supporting these opportunities and will include a panel of three speakers from payer organizations, each of whom will provide an overview of their experience and results in innovating in the use of technology to address unmet enrollee health needs. Panelists include Mona Siddiqui MD, MPH, Senior Vice President for Enterprise Clinical Strategy and Quality at Humana, who will discuss Humana’s approach to the use of data and predictive modeling to proactively engage and provide care for the highest risk and most vulnerable populations; John Wiecha, Medical Director, Senior Products Division at Point32Health, representing the newly combined organizations of Harvard Pilgrim Health Care and Tufts Health Plan will provide an overview of a recent pilot project to improve dementia care through a digital caregiver support program; and Caesar A. DeLeo, MD, MHSA Vice President & Executive Medical Director Strategic Initiatives, Highmark Health Enterprise Clinical Organization, Highmark BCBS who will discuss Highmark’s experience with telemedicine to approach substance use disorders during the pandemic and results from a five-year data driven program addressing appropriate opiate prescribing through profiling and academic detailing.
The webinar offers attendees the opportunity to gain a better understanding of the evidence and potential of several technology-enabled services in improving access, quality and outcomes of care, including, importantly, for underserved populations and will provide MAOs with insights more broadly on the challenges and solutions in design, implementation and evaluation of innovative and technology-enabled service. MAOs that are considering such innovations who may wish to target the use of technology-enabled and/or other services based on chronic illness and/or Low-Income Subsidy (LIS) status through the VBID Model are encouraged to attend.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Next Generation ACO Model team hosted an open door forum on Tuesday, January 31, 2017. During this open door forum Model team members provided an overview of the Model, along with information pertaining to the Letter of Intent (LOI).
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held the second in a series of webinar events for the Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model on Wednesday, June 8, 2016 from 12:00p.m. – 1:30p.m. EDT. This webinar consisted of a panel discussion focusing on learning from past ESCO participants on what it takes to become a successful applicant and successful ESCO.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
In follow-up to the March 10, 2015 announcement of the Next Generation Accountable Care Organization (ACO) Model of payment and care delivery, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted a repeat of the first open door forum in a series focusing on various aspects of the Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document provides an overview of the Part D Senior Savings Model proposed by CMS Innovation Center. The model aims to lower out-of-pocket costs for insulin by establishing a stable $35 copay for eligible insulins through the deductible, initial coverage, and coverage gap phases of Part D plans. The model would be voluntary for manufacturers, Part D plans, and beneficiaries. It also outlines the application process and timelines for manufacturers and Part D plans to participate in the 2021 plan year.
The Next Generation ACO Model team hosted an open door forum on Tuesday, March 28, 2017. The Next Generation Model features three payment rule waivers, referred to as benefit enhancements. This open door forum provided an overview of the Model’s three benefit enhancements.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
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The CMS Innovation Center held the fourth in a series of webinars for potential applicants interested in applying to Health Care Innovation Awards Round Two. The webinar held on Thursday, June 20, 2013 from 1:00–2:00pm EDT, focused on how to achieve lower costs through improvement. This webinar also reviewed the components of the Financial Plan.
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CMS Innovations
http://innovations.cms.gov
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The document provides information about Accountable Care Organizations (ACOs) and the Medicare Shared Savings Program proposed by CMS. It explains that ACOs allow groups of healthcare providers to coordinate care for Medicare patients, with the goals of improving quality of care and reducing costs. Providers can form or join ACOs to participate in the program. ACOs will be evaluated on quality measures and their ability to lower healthcare spending compared to spending benchmarks. ACOs that meet quality standards and reduce costs below their benchmark can earn a share of the savings, with larger rewards available to ACOs that take on two-sided risk models involving potential loss sharing as well.
This document provides an overview of accountable care organizations (ACOs). It discusses that ACOs aim to improve care management, limit unnecessary expenditures, and provide patient freedom of choice while making providers financially accountable. The document outlines the principles of ACOs, their relationship to the Patient Protection and Affordable Care Act, payment models, quality measures, stakeholders, and challenges of implementing ACOs.
DeMarco and Associates and Pendulum HealthCare Corporation provide services to help organizations develop accountable care organizations (ACOs). They assist with infrastructure development, care coordination, and data analytics. Pendulum also designs, develops, and manages ACOs. An ACO aims to deliver coordinated, efficient care to a defined patient population through provider collaboration and accountability for costs and quality outcomes. Requirements include agreements between primary care physicians, specialists, and hospitals to be responsible for a minimum number of Medicare beneficiaries.
Accountable Care Organizations: 4 Physician BenefitsGreenway Health
Why would physicians join an Accountable Care Oragnization (ACO)? This informative slide presentation gives a brief overview of ACOs, their benefits, and four reasons physicians may have for joining one.
The document discusses opportunities around accountable care organizations (ACOs) and bundled payments under healthcare reform legislation. It outlines proposed ACO pilots that would test payment models to reduce costs and improve outcomes. It also discusses proposals for bundled payment pilots for post-acute care services beginning in 2011. Key questions are raised around which providers can participate in ACOs, what organizational structures and partnerships may look like, and how providers can position themselves for these new models.
The document provides an overview and agenda for a presentation on Accountable Care Organizations (ACOs) and the Next Generation ACO model. It discusses the background and objectives of ACOs, the purpose and components of the Next Generation ACO model, comparisons between traditional and Next Generation ACOs, financial timelines and calculations, risk arrangements, payment mechanisms, and conceptual diagrams. Contact information is provided for follow up.
An Accountable Care Organization (ACO) is a provider-led organization that manages the full continuum of care for a defined patient population to improve quality and reduce costs. The US healthcare system lacks coordination and incentives for value over volume, motivating ACO development. ACOs differ from 1990s integrated delivery systems by focusing on managing performance risk rather than insurance risk through tools like bundled payments, quality tracking, and health IT. Critical functions include attributing patients, budgeting, performance measurement, and managing payment models to distribute shared savings incentives.
- Medicare's Accountable Care Organization program allows groups of doctors/hospitals to be paid for helping Medicare patients stay healthy. Over 200 organizations are deciding whether to continue in the program.
- New rules proposed by Medicare allow groups to remain in the lowest-risk program for 3 more years or join a new higher-risk/higher-reward program.
- While these groups have saved Medicare money, Medicare has retained more savings than the groups themselves due to the rules of the program. Some experts argue these groups could see higher rewards by taking on more risk through other Medicare programs.
This document provides an overview of various Accountable Care Organization (ACO) models in the US healthcare system, including their evolution and performance over the last 5-6 years. It highlights the key growth drivers and success factors for ACOs, such as gaining experience in the program, having larger networks, and utilizing data analytics technologies. The document also analyzes different ACO models based on factors like their benchmark methodology and risk/reward arrangements. Its intended audience includes health systems and payers interested in forming their own ACO networks.
The document discusses health care reform under the Affordable Care Act and new models of care, specifically Accountable Care Organizations (ACOs). It provides an overview of the key elements of ACOs, noting they accept responsibility for quality and cost of care for a defined patient population. The document contrasts old models like PHOs with the new ACO model, which emphasizes coordinated, patient-centric care paid for based on quality rather than volume of services.
The document discusses Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program. It explains that ACOs are groups of doctors, hospitals, and other health care providers that come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of ACOs is to ensure patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. The document provides details on ACO legal structures, governance, operations, payment models, and audits to ensure compliance with program rules.
Population Health Management: Enabling Accountable Care in Collaborative Prov...Salus One Ed
This document provides the reader information about population health management (PMH), how it relates to incentive payments for healthcare providers and their health insurance partners (commercial and government). See details about required transformation of care delivery methods, typical accountable care payment models, how to achieve incentives, partnerships between state government (public health) and community shared services needs and necessary technology and data to achieve it.
Center for Medicare and Medicaid Innovation & ACOsGreenway Health
Learn more about the $10-billion initiative created under the Patient Protection and Affordable Care Act. Accountable Care Organizations strive to build community-based care and payment models to benefit both provider and patient. The risks, rewards, and other incentive information are explained in our ACO series.
PoV examines key steps payers must take to establish and successfully manage ACOs - enhancing their ability to remain competitive through 2012 and beyond
Resetting Payer-Provider Arrangements for COVID-19 and the Evolving Improveme...Health Catalyst
As the healthcare industry recovers from COVID-19, providers are re-evaluating the financial arrangements that motivate them to improve their processes while benefiting payers and patients.
With the pandemic driving lower provider volumes and straining hospital resources, the industry has a renewed urgency for policies that drive better outcomes while lowering cost and improving revenue. Moving forward, healthcare must reset its payer-provider performance standards to the post COVID-19 environment.
Renewed approaches to the following models will consider the impact of remote care, how to reimburse telehealth services, and the need for consistent payments to providers:
1. Pay for performance.
2. Bundled payments.
3. ACOs.
What is an Accountable Care Organizations (ACO) How does an ACOs .pdfwasemanivytreenrco51
What is an Accountable Care Organizations (ACO)? How does an ACO\'s economics work to
manage costs and quality?
Solution
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care
providers, who come together voluntarily to give coordinated high quality care to their Medicare
patients.
An accountable care organization (ACO) is a healthcare organization characterized by a payment
and care delivery model that seeks to tie provider reimbursements to quality metrics and
reductions in the total cost of care for an assigned population of patients. A group of coordinated
health care providers forms an ACO, which then provides care to a group of patients. The ACO
may use a range of payment models (capitation, fee-for-service with asymmetric or symmetric
shared savings, etc.). The ACO is accountable to the patients and the third-party payer for the
quality, appropriateness and efficiency of the health care provided. According to the Centers for
Medicare and Medicaid Services (CMS), an ACO is \"an organization of health care providers
that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who
are enrolled in the traditional fee-for-service program who are assigned to it.
Design and Structure
There is no single organizational model for developing an ACO. ACOs may be formed and
organized by health systems using employed and contracted physicians, by integrated delivery
systems, by physician groups (either primary care or multispecialty) or through joint ventures or
contractual relationships among providers. Regardless of the organizational structure, an ACO
must be physician-led and physician-driven. Physician leadership is critical because an ACO is
primarily a vehicle for clinical integration, not financial or risk integration. Only physicians are
able to develop, monitor and adjust clinical care protocols that can more efficiently use resources
based on documented effectiveness.
Qualifying ACOs will be assigned a pool of patients whose care the ACO will be responsible for
managing in a cost-effective and clinically appropriate manner. The ACO will need to develop
internal mechanisms for monitoring and managing costs and quality that cut across traditional
reporting lines and result in a higher degree of clinical interdependence than is typical in a less-
integrated medical community.
The PPACA states that any of the following groups of providers of services and suppliers that
have established a mechanism for shared governance are eligible to participate, in accordance
with regulations to be developed by the Secretary of Health and Human Services (HHS):
ACOs Under Health Reform
Section 3022 of PPACA requires HHS to establish a shared savings program under which
qualifying ACOs may be eligible for incentive payments. The criteria in the statute, which will
need to be further defined by regulation, include:
ACOs will be required to measure and report their progress to HHS, includ.
Top 5 Things To Learn About CMS ACO Reach.pptxPersivia Inc
In today's ever-evolving healthcare landscape, the Centers for Medicare & Medicaid Services (CMS) constantly introduce new programs and models to improve the quality and efficiency of healthcare delivery. One such initiative is the CMS ACO Reach Platform.
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
The Healthcare Quality Coalition wrote to CMS Administrator Berwick to provide feedback on the proposed Medicare Shared Savings Program and ACO regulations. The coalition supports the goals of improved care coordination and reduced costs through alternative payment models like ACOs. However, the letter outlines several concerns with the proposed rule, including that it requires reporting on too many quality measures in year one, does not adequately account for patient acuity, and may not provide sufficient incentives for high-quality organizations to participate. The coalition urges CMS to address these issues in the final rule.
Similar to Mark Zezza: Moving towards accountable care in the US (20)
This document discusses the potential impacts of automation on healthcare employment and discusses alternative views beyond job loss. It notes that automation may lead to reconfiguring of healthcare work rather than outright job loss. Examples of existing technologies that have automated tasks in healthcare like pharmacy automation and emerging technologies like decision support systems and personal health tracking are provided. The document advocates that automation could lead to a virtuous cycle in healthcare if it allows workers to focus on tasks that require human skills and judgment.
Evaluation of the Integrated Care and Support Pioneers ProgrammeNuffield Trust
This document summarizes the findings of evaluations of the Integrated Care and Support Pioneers Programme in the UK. The evaluations found that while Pioneers aspired to comprehensive system change, their activities focused more narrowly on initiatives like risk stratification and care coordination teams. Progress was difficult to measure against indicators and Pioneers faced challenges from financial pressures and competing priorities. The evaluations concluded that further integration will be challenging under increasing demands on the health system.
The document discusses lessons learned from the Southwark and Lambeth Integrated Care (SLIC) program in London. Key points:
- SLIC aimed to reduce hospital admissions and care home placements for older adults through risk stratification, holistic assessments, and care management.
- Success required agreement on the problem, dedicated teams, funding shifts to support community care, and leadership development.
- Future programs need a strong business case, co-design with citizens, and a dedicated "engine room" team to drive local transformation.
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Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
Ramani Moonesinghe, Associate National Clinical Director for Elective Care at NHS England, discusses the use of data for monitoring care quality at various levels within the system.
This document discusses using statistical process control (CUSUM) charts to monitor mortality rates at the level of individual general practitioners and health authorities. It describes how CUSUM charts could potentially have detected Harold Shipman, a GP who murdered over 200 patients, by spotting outliers in the routine mortality data. The document also discusses challenges in risk adjusting outcomes to account for differences in patient characteristics and casemix between providers. Accurately adjusting for factors like age, comorbidities, and emergency status is important for fair comparisons but difficult using only administrative data.
Martin Utley, Director of the Clinical Operational Research Unit at University College London, reflects upon his involvement in the launch of specific tools to monitor care quality for paediatric cardiac surgery.
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- Real-time monitoring of healthcare services requires defining both a reporting window and data window to accurately capture demand, activity, and wait times.
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Mark Zezza: Moving towards accountable care in the US
1. Affordable Care Act: Delivery System Change
Moving Towards
Accountable Care
Mark Zezza
Senior Policy Analyst
The Commonwealth Fund
2. Agenda
• Vision for Health Care Reform
• How Accountable Care Organizations (ACOs)
help achieve that Vision
• Early Evidence on ACOs
• How ACOs fit with Other Reform Efforts
3. Current State of Vision for Future:
Health Care in US Reflected in Affordable Care Act
• Unclear Aims: conflicts about what • Clarify Aims: better overall health and
trying to produce experiences at lower costs for patients
• Fragmentation: no accountability • Care Coordination: foster accountability for
for capacity, quality or costs full continuum of care
• Lack of information: leaves • Better information: supports improvement;
practices unexamined informs consumers for best care
• Wrong Incentives: Rewards • Payments to support efficient care: Align
fragmentation and inefficiency financial incentives with professional aims
4. Accountable Care Organizations Central to
Achieving Vision
Medicare Shared Savings Program (MSSP)
Set to begin April 1, 2012
CMS estimates 50-270 ACOs (1-5 million beneficiaries)
will participate between 2012 – 2015
https://www.cms.gov/sharedsavingsprogram/
Pioneer ACO Program
Began January 1, 2012 – 32 organizations selected
Designed for more advanced ACOs
http://innovations.cms.gov/initiatives/aco/pioneer/
Advanced Payment Model
Upfront payments to help provider groups ramp up for ACO initiatives
Focused on smaller physician groups or small hospitals serving rural or
underprivileged communities
http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-
payment/
5. Agenda
• Vision for Health Care Reform
• How Accountable Care Organizations (ACOs)
help achieve that Vision
• Early Evidence on ACOs
• How ACOs fit with Other Reform Efforts
6. Simple Definition of ACOs
local (and legal) entity, comprised of a group of providers that
can be held accountable for the cost and quality delivered to a
defined population of patients
Not Mythical No One
Creatures Size Fits All
“itsabout
accountable
care, not just
organizations”
– Stu Guterman
ACOs are real but not a Flexible model
Panacea fosters local
accountability
7. ACO Core Features
Strong primary care foundation
Able to manage patient services across the full continuum of care.
Enough primary care to support generate population-level impacts
• Sufficient size to support meaningful measurement of cost and
quality impacts
— MSSP - Assignment for at least 5,000 Medicare beneficiaries
— Pioneer – 15,000 (rural Pioneers can have 5,000)
Strong organizational, legal and governance structure
Capable of prospectively planning budgets and resource needs as
well as internally distributing payments (shared-savings)
Leadership is key to change culture of physicians
Accountability for total cost of patient care
For all services (even by non-ACO providers) and patient co-pays
Ability to report on a robust set of Performance Measures
8. How are Patients Assigned to the ACO?
Basic Patient Attribution
Approach:
Step 1. Providers sign agreement
to participate with ACO
• ACO sends list of participating
providers to partnering Payer
Step 2. Payer assigns members
to providers based on plurality of
patient’s primary and
preventative care utilization (or
charges)
• If assigned provider is in an
ACO, the member gets
assigned to the ACO
• CMS first assigns to primary
care providers, then others
(specialists and nurses)
9. Patient Attribution Issues to Consider
Attribution versus Attestation and Member Notification
Attribution is most used, but Attestation is useful when no recent primary care
• Attestation may be tested in Pioneer ACO Model
CMS requires notification of data-sharing and opt-out (but still counted in ACO)
• ACOs must also make informational materials available
Providers used for attribution must be exclusive to one ACO
Easier to attribute ACO performance and limits concerns about patient
selection/dumping
Concerns over locking in a specialist to a specific ACO
Prospective versus Retrospective
Both approaches have pros and cons, for example:
• (Theoretically) greater incentive for ACO to treat all patients equally under
retrospective approach, whereas prospective allows better budgeting
CMS tries to achieve best of both worlds
• Initial prospective attribution with final reconciliation at end of
performance period
• Pioneers may test prospective assignment
10. Basic Shared Savings Model
ACO Launched Projected Spending
Target Spending
Shared Savings
Actual Spending
Project benchmark spending in the performance period from
the historical baseline amounts
Incorporate a savings threshold (e.g., 2%) to determine the
spending target for calculating shared savings
• Thresholds used to ensure no random winning
If actual spending is below target then ACO would be eligible for
shared savings
• Only paid out if quality threshold is met/exceeded
11. Shared Savings Offers a
Wide Range of Approaches
One-Sided Two-Sided Capitation
Continue operating under Payments can still be tied to ACO receives prospective fixed
current insurance current payment system, payment
contracts/coverage models although ACO could receive
If successful at meeting budget
(e.g., FFS) revenue from payers and
and performance targets,
distribute funds to members
No risk for losses if spending greater financial benefits
exceeds targets At risk for losses if spending
If ACO exceeds budget, more
exceeds targets
Most incremental approach risk means greater financial
with least barriers for entry Increased incentive for downside
providers to decrease costs
Attractive to new entities, Only appropriate for providers
risk-adverse providers, or Attractive to providers with with robust infrastructure,
entities with limited some infrastructure or care demonstrated track record in
organizational capacity, coordination capability and finances and quality and
range of covered services, demonstrated track record providing relatively full range
or experience working with of services
MSSP – offers a two-sided
other providers
track with 60% savings. All Ultimate goal for most ACOs
MSSP – ACOs can participate ACOs must participate in 2-
Pioneer – in 3rd year, high-
in one-sided model, with sided model after 3rd year
performing ACOs have option
50% savings for 1st 3 years.
Pioneer – Offers greater for partial capitation for Part B
Pioneer: Offers a 1-sided potential (up to 75%) for services or full capitation,
option for one year shared savings earnings including Part A and Part B
12. Risk Adjustment, Corridors and Thresholds
CMS will risk adjust spending estimates using demographic factors,
diagnoses and procedure codes from historical claims (CMS-HCC model)
Problems with “up-coding” in pervious ACO demonstration
• Participating providers have greater incentive to code fully
Decision to update risk scores for newly assigned beneficiaries to account for
differences in health status relative to continuously enrolled
• Reduces incentive for ACO to avoid sicker patients
For currently enrolled, will use Age-Sex factors to update risk score
Cap on savings (losses)
Vary from 5% – 15% with higher risks aligned with greater reward potential
Minimum savings (loss) thresholds to ensure paying for intended
improvements rather than random chance
MSSP – varies from 2.0% - 3.9% depending on size for one-sided model and
flat 2.0 percent for two-sided model
Pioneer – typically flat 1.0%
Share on 1st dollar basis once surpass the threshold
13. Performance Measurement
Critical to ensure that ACOS are not just stinting on care to stay
under budgets
33 measures with 4 domains:
– Patient/caregiver experience (7)
– Care coordination/patient safety (6)
– Preventive health (8) and,
– At-Risk Populations (12)
• diabetes (6), hypertension(1), IVD (2), heart failure (2), CAD (2)
Phase-in Approach
– Year 1: Pay for reporting (all 33)
– Year 2: Reporting(8) Performance(25)
– Year 3: Reporting(1) Performance(32)
ACO must surpass threshold on 70% of measures within each
domain
14. Agenda
• Vision for Health Care Reform
• How Accountable Care Organizations (ACOs)
help achieve that Vision?
• Early Evidence on ACOs
• How ACOs fit with Other Reform Efforts
15. ACO Movement
2009 January 2012
Private Sector Public Sector
= Brookings-Dartmouth Pilots (5) = AQC (9 in Massachusetts) = Beacon Communities (13)
= Premier Implementation (23) = AMGA Collaborative (16) = PGP, MHCQ (13)
= CIGNA (12) = Other private-sector ACOs = Pioneer (32)
Notes: AMGA = American Medical Group Association; AQC = Alternative Quality Contract; PGP = Medicare Physician Group
Practice Demonstration; MHCQ= Medicare Health Care Quality Demonstration.
Source: Brookings Dartmouth ACO Learning Network Collaborative.
16. Medicare Physician Group Practice (PGP) Demonstration
Provides Early evidence on shared savings in multispecialty groups
Background: 10 integrated multispecialty provider groups testing care reforms for
Medicare beneficiaries under a shared-savings payment model (started 2005)
Quality performance: After 5 years, all 10 sites achieved benchmark performance on at
least 30 of 32 measures
– Share in more savings with better performance
– 5- year percentage-point average increases:
• 11% on diabetes measures
• 12 % on heart failure measures
• 6 % on coronary artery disease measures
• 9 % on cancer screening measures
• 4 % on hypertension measures
Cost Performance: Achieved over $134 million in savings relative to similar cohort of
patients. Nearly $110 went back to the providers.
Measure of success: All groups agreed to a 2-year extension (through 2012)
Source: https://www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=CMS1198992
17. BCBS Massachusetts:
Alternative Quality Contract
• The BCBS AQC is an innovative global payment model with
substantial performance incentive payments
– Negotiates budgets with each organization based on historical spending
• Over time, budgets linked to growth in overall economy
– Groups still paid based upon Fee-for-Service with end-of-year
reconciliations
– Groups bear between 50% - 100% of the risk for excess costs
– Performance bonuses available up to 10% of budget
• 8 diverse organizations signed a 5-year contract in 2009
– Represented more than 25% of the state’s providers and 305,000 BCBS
members
– Up to 12 groups and 470,000 members (as of 1/2011)
– Caveat – HMO members only
• Initial results show that all groups are hitting quality targets and
there is evidence for reduced costs
18. AQC Associated with Smaller Spending Increase:
6.8% vs. 8.8%
Average total quarterly spending per enrollee,
in dollars
Source: Z. Song, D. G. Safran, B. E. Landon et al., "Health Care Spending and Quality in Year 1 of the Alternative Quality
Contract," New England Journal of Medicine, published online July 13, 2011.
19. How do Providers/ACOs Succeed at improving
outcomes, care and costs?
ACOs in the Alternative Quality Contract:
Price decreases from shifting care to providers that charge
lower fees
• Reduce network leakage
– Helps coordinate care more effectively
– Replace lost patient volume from more efficient care
– Direct care away from more expensive places
Managing high-risk patients
• Reduce services with limited value (avoidable admissions,
readmission and ER visits)
• Expand home visits, better discharge planning, etc…
• Better patient education and medication/therapy compliance
• Predictive Risk Models
Source: Z. Song, D. G. Safran, B. E. Landon et al., "Health Care Spending and Quality in Year 1 of the Alternative Quality
Contract," New England Journal of Medicine, published online July 13, 2011.
20. How do Providers/ACOs Succeed at improving
outcomes, care and costs?
Through systematic efforts to improve quality and reduce
costs across the organization:
– Reduce avoidable admissions and ER visits
– Using appropriate workforce (increased use of NPs)
– Improved care coordination
– Reduced waste (i.e. duplicate testing)
– Internal process improvement
– Better patient adherence to recommended care
– Point of care reminders and best-practices
– Savings in hospital supply costs
– Actionable, timely data
– Choices about capacity
Initiatives will vary with each organization
21. Risk Sharing Within ACOs
ACO framework transfers financial risk from payers to ACO
Individual providers are indirectly affected
Ideally Shared Savings should at least support investments for shared
resources (i.e., HIT, discharge planners, etc…)
ACOs taking on greater risk (e.g., capitation) should have better care
management expertise
• State licensing and regulatory requirements to protect solvency
Wide variation in how ACOs pay and share risk with its providers
Can take capitation from payer, but pay providers on FFS basis
Bonus potential (up to 1/3 of compensation)
Tradeoffs between exposing individuals to risk of non-performance by
others and rewarding only individual performance
Individual incentives aligned with overall ACO aims
Challenge in achieving shared vision of leadership team and
governing boards to support move toward accountable care
Changing provider culture and patient behavior
Medicare: No enrollment, no lock-in, no change in benefits
Shared Savings is likely a modest financial incentive, especially for
ACOs still working with FFS payment
• Money is not only motivator
— Improve ability to practice better health care
— Better quality of life (greater fulfillment)
22. Culture Change
• Early and critical step for accepting accountability
• Requires evolution in relationship between providers, payers and
patients
• Providers and payers must move beyond adversarial negotiations around
payment rates toward collaborations for more efficient care. Not only
about payment reform, but also data analytics and benefit redesign to
support higher-value care.
• Providers and other providers need to become better at working with each
other to coordinate care – includes sharing expert opinions and
synthesizing patient-centered outcomes research to develop practice-
changing innovations.
• Providers and patients also need to work better together. Requires time to
equip patients, and their care support team, with the information needed
to feel confident about making efficient and effective health care decisions.
• ACO movement is a great signal that the cultural change is happening -
“Intellectual Energy”
• Will not be easy, there will be failures as well as success
• Need strong commitment and vision
23. Agenda
• Vision for Health Care Reform
• How Accountable Care Organizations (ACOs)
help achieve that Vision?
• Early Evidence on ACOs
• How ACOs fit with Other Reform Efforts
24. Health Reform is Much More than ACOs:
Activities in Center for Medicare & Medicaid Innovation
1 Advance Payment ACO Model Provides upfront capital to rural and small providers to
help them become ACOs
2 Pioneer ACO Model Tests advanced ACO models
3 Bundled Payments for Care Tests 4 bundled payment models covering physician,
Improvement hospital and post-acute care services
4 Comprehensive Primary Care Multi-payer initiative to strengthen primary care.
Initiative
5 Federally Qualified Health Center Advanced Primary Care Practice Demonstration
6 Multi-payer Advanced Primary Multi-payer medical home pilot in 8 states
Care
7 Financial Models to Support State Efforts to Integrate Care for Medicare-Medicaid
Enrollees
8 State Demonstrations to Integrate Provides $1M planning grants to states to develop new
Care for Dual Eligibles ways to meet the needs of the dual eligible population
9 Innovation Advisors Program Creates a network of delivery system reform experts
10 Reducing Preventable Hospitalizations Among Nursing Facility Residents
11 The Health Care Innovation Makes up to $30 million available to support providers in
Challenge their reform efforts
12 Partnership for Patients Aims to prevent preventable hospital admissions and
complications
25. Strategic Implementation of Reforms
Payment models are complimentary -
ACOs – Accountability of all services for an entire population,
which helps ensure no cost-shifting and overall policy goals of
better health and lower total costs are being met
Bundled Payments – Accountability for select services and
conditions, which helps ensure important gaps in care are
addressed and specialists are included in efforts to better
coordinate care
Need to experiment with different approaches
Not sure what works best
Vary with local market characteristics and provider experience
with care management
Providers will need to leverage multiple payment reform
provisions to maximize returns on clinical transformation
efforts
26. How can ACOs fit in a National Health System?
(from a US perspective)
Who should assume accountability for value of care?
Accountability requires coordinated care over time, as well as across multiple
providers and institutional settings
1. Individual providers? may have to narrow a focus – on specific
patient provider interactions – and not enough resources
2. Health Plans? In good position to facilitate care coordination and
accountability for patient outcomes, but historically have been more
focused on costs than value
• 60% of Americans with employer-sponsored insurance
companies work for self-insured employers
3. ACOs? Seems like the right fit
ACOs offer a global budget approach with flexibility to accommodate various
underlying payment and delivery models
Potential to align payment models and incentives across payers
• Critical Mass of volume and types of providers needed to have significant
impact on care and enough financial support to implement reforms
Anticipates increasing challenges of FFS payment environment while preserving
or increasing net revenues - with a progressive approach