1 Getting Started in a Medicare Shared Savings Program Accountable Care Organization Tuesday, September 16 th Pam Maxwell, Chief Growth Officer
What is an ACO? 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. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. http://www.cms.gov/medicare/medicare-fee-for-service-payment/aco/index.html?redirect=/aco/ 2
Evolving Healthcare Landscape The health care industry is rapidly moving to more value-based reimbursement and care delivery models. Full Risk Delegated Risk IDN Health Plan Model Medicare Advantage Global Capitation Transactional Care Management Employee Programs CMS Bundled Payment Programs CMS Pioneer ACOs Integrated Care Management Narrow Networks MSSP & Commercial ACOs PCMH Fee For Service
Early Value-Based Adoption Benefits Increase Revenue Improve Patient Care Coordination Shared Savings with Care Partners Low Risk Learning Post Acute, Reduced Readmissions and other savings opportunities Better care coordination, seamless transitions and improved communication throughout patient care episode Physicians in the program can enjoy shared savings benefits to increase their earnings, as well as better care coordination for their patients Good first step for learning how to manage care under a value-based contract
ACOs across the Country TYPES Hospital-led Hospital-physician groups Independent physician groups 360+ MSSP ACO s 520 Total January 2013 +106 January 2014 +123
Successful ACOs have these Objectives Improve patient outcomes Enhance quality of care Reduce overall cost of care Increase practice revenue and drive growth Focus on The Patient, Improve Practice Flow and Lower Medical Costs 6
Simply Learn how to manage medical costs Provide quality care to patients based on outcomes 7
WIIFM? 8
Care & Feeding of a MSSP ACO 9
Realities for an ACO Startup Capital Providers Contract(s) Infrastructure Technology & analytics Care coordination Administration 10
Reality #1 - It Takes Money Consider potential investors providers, business associates, other healthcare partners Up to $1.5M+ to fund operations for 18 months Executive leadership & staff Software & analytics capabilities Care coordination resources Board & business meetings Patient engagement communications Business partners with existing infrastructure can help to lower these costs 11
Reality #2 You Need Providers Primary care providers bring the patients CMS and other payer attribution can be lower than you think Average 25-50 providers needed for 5,000 Medicare FFS lives depending on market dynamics 12
Reality #3 Financial Incentives are Key CMS Medicare Shared Savings Program is a ready place to start Other payer contracts for traditional FFS patients may be available Traditional managed care contracts won t necessarily pay you more for an ACO structure 13
Reality #4 Creating Sustainable Results Requires infrastructure and capabilities Technology, data management and analytical capabilities Care coordination, which may require resources beyond current practice capabilities Administration CMS requirements, ongoing patient communications and general business management of ACO operations 14
Reality #1 It Takes Money Shared savings is the reward and the path to future funding of ACO operations No medical cost reduction = no meaningful payments Medical cost savings must be your focus Turn big data into feasible action Develop realistic programs that make a difference Execute relentlessly across practices Coding matters 15
But what about the other two aims? High costs do not equate to high quality Reducing overutilization and medical waste improves patient experience Quality oversight and preventive care are critical to sustaining a new normal of medical cost once achieved 16
Panel Discussion 17