Creation of the Center for Medicare and Medicaid Innovation & ACOs Adele Allison, National Director of Government Affairs,...
Created under  § 3021  of Patient Protection & Affordable Care Act $10 Billion  allocated   for FY2011 - 2019
Focus on Government Health Programs Medicaid, Medicare, Children’s  Health Insurance Program
Empowered by Congress - Flexibility  in selecting and testing new payment models -Secretary allowed  broad discretion  in ...
Spotlight on  decreased costs  &  increased quality
Four Mission Domains 1. Patient Care Models -Bundled Payments 2. Seamless & Coordinated Care Models -ACOs & PCMHs
Four Mission Domains 3. State Engagement Models -1,200 medical homes; Medicaid Health Home State Plan (2 years 90% funded ...
CMMI & ACOs
PPACA requires CMS to start contracting  CY2012
What is an  Accountable Care Organization (ACO) ? “Groups of doctors, hospitals, and other health care providers, who come...
Three types of CMMI  ACOs 1. Shared-Savings ACO 2. Advanced Payment ACO 3. Pioneer ACO
ACO Final Rule: Applications open  Jan. 1, 2012
Two initial launch dates:  April 1, 2012  & July 1, 2012
CMS anticipates  270   ACOs   to form
Medicare Shared-Savings ACO
Heart of the ACO Final Rule issued  Oct. 20, 2011
Minimum  5,000  Medicare PFS Beneficiaries
Two Models One-Sided , No Risk = 50% sharing in savings created Two-Sided , Limited Risk = 60% sharing in savings created
One-Sided -Physicians paid  FFS , as usual -If savings is created AND performance measures achieved,  50/50 split -If ACO ...
Two-Sided -Physicians paid  FFS , as usual -If savings is created AND performance measures achieved,  60/40 split -If ACO ...
Advanced Payment ACO
Created to help  MD-owned  and/or  Rural Providers
Limited to Two Organizational Types  1.  ACOs with  no inpatient  and annual  revenue of < $50 million 2. ACOs with  inpat...
Three Payment Types 1.  Upfront Fixed  Payment 2.  Upfront  Payment   based on historically-assigned beneficiaries 3.  Mon...
ACO application must be made for both  Shared-Savings  and  Advanced Payment
No  health plan ownership allowed
Pioneer ACO
Created for Advanced Health Organizations
Minimum  15,000  aligned beneficiaries
Not  subject to the ACO Final Rule – Separated Model
Intent of the Model -Allow advanced systems to move quickly to population-based payment model -Work in coordinating model ...
Pioneers  would have a  higher share  in savings created
Pioneers  also have a  higher share  in risk
Pioneers  have broadened control over community-based  rewards  and  consequences
For more information about  industry trends, visit  www.successehs.com  for white papers, articles, blog posts and more! C...
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Center for Medicare and Medicaid Innovation & ACOs

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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.

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Center for Medicare and Medicaid Innovation & ACOs

  1. 1. Creation of the Center for Medicare and Medicaid Innovation & ACOs Adele Allison, National Director of Government Affairs, SuccessEHS
  2. 2. Created under § 3021 of Patient Protection & Affordable Care Act $10 Billion allocated for FY2011 - 2019
  3. 3. Focus on Government Health Programs Medicaid, Medicare, Children’s Health Insurance Program
  4. 4. Empowered by Congress - Flexibility in selecting and testing new payment models -Secretary allowed broad discretion in rulemaking
  5. 5. Spotlight on decreased costs & increased quality
  6. 6. Four Mission Domains 1. Patient Care Models -Bundled Payments 2. Seamless & Coordinated Care Models -ACOs & PCMHs
  7. 7. Four Mission Domains 3. State Engagement Models -1,200 medical homes; Medicaid Health Home State Plan (2 years 90% funded for chronic dz. or mental illness) 4. Community & Population Health Models -Public Health (ex: smoking, obesity)
  8. 8. CMMI & ACOs
  9. 9. PPACA requires CMS to start contracting CY2012
  10. 10. What is an Accountable Care Organization (ACO) ? “Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.”
  11. 11. Three types of CMMI ACOs 1. Shared-Savings ACO 2. Advanced Payment ACO 3. Pioneer ACO
  12. 12. ACO Final Rule: Applications open Jan. 1, 2012
  13. 13. Two initial launch dates: April 1, 2012 & July 1, 2012
  14. 14. CMS anticipates 270 ACOs to form
  15. 15. Medicare Shared-Savings ACO
  16. 16. Heart of the ACO Final Rule issued Oct. 20, 2011
  17. 17. Minimum 5,000 Medicare PFS Beneficiaries
  18. 18. Two Models One-Sided , No Risk = 50% sharing in savings created Two-Sided , Limited Risk = 60% sharing in savings created
  19. 19. One-Sided -Physicians paid FFS , as usual -If savings is created AND performance measures achieved, 50/50 split -If ACO exceeds per capita benchmark, no downside
  20. 20. Two-Sided -Physicians paid FFS , as usual -If savings is created AND performance measures achieved, 60/40 split -If ACO exceeds per capita benchmark, fee adjustment occurs (capped)
  21. 21. Advanced Payment ACO
  22. 22. Created to help MD-owned and/or Rural Providers
  23. 23. Limited to Two Organizational Types 1. ACOs with no inpatient and annual revenue of < $50 million 2. ACOs with inpatient through CAHs/Rural hospitals and revenue of < $80 million
  24. 24. Three Payment Types 1. Upfront Fixed Payment 2. Upfront Payment based on historically-assigned beneficiaries 3. Monthly Payment based on historically-assigned beneficiaries
  25. 25. ACO application must be made for both Shared-Savings and Advanced Payment
  26. 26. No health plan ownership allowed
  27. 27. Pioneer ACO
  28. 28. Created for Advanced Health Organizations
  29. 29. Minimum 15,000 aligned beneficiaries
  30. 30. Not subject to the ACO Final Rule – Separated Model
  31. 31. Intent of the Model -Allow advanced systems to move quickly to population-based payment model -Work in coordinating model with private payers to align quality and outcome incentives
  32. 32. Pioneers would have a higher share in savings created
  33. 33. Pioneers also have a higher share in risk
  34. 34. Pioneers have broadened control over community-based rewards and consequences
  35. 35. For more information about industry trends, visit www.successehs.com for white papers, articles, blog posts and more! Click here for our industry blog

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