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11 Responses

  1. 6 burning questions about ACOs

    While healthcare spending continues to rise, industry stakeholders are desperate to see something succeed in ensuring care quality and containing costs.

    Accountable care orgnizations are captivating because they contain elements of care delivery that most experts agree should bring about improvements: financial risk sharing, electronic health records, quality benchmarks, patient engagement and care coordination, to name a few.

    http://www.medicalpracticeinsider.com/best-practices/answers-your-6-burning-questions-about-acos?email=%%EmailAddress%%&GroupID=116654&mkt_tok=3RkMMJWWfF9wsRonuKnMZKXonjHpfsX56O0kXK6zlMI%2F0ER3fOvrPUfGjI4AScJlI%2BSLDwEYGJlv6SgFQ7LHMbpszbgPUhM%3D

    But the question remains: can ACOs pull it off.

    Alan

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  2. Medicare’s Pioneer Program Down to 19 ACOs After Three More Exit

    Three more accountable care organizations dropped out of Medicare’s Pioneer program, which was designed to test the payment and delivery model with a small group of elite providers deemed best prepared to handle the operational demands and financial risks. The Franciscan Alliance, Genesys PHO, and Renaissance Health Network have exited the program, which is now in its third year. In August, Sharp HealthCare, San Diego, announced its decision to pull out after determining “the model was financially detrimental”, despite the ACO’s performance managing quality and healthcare use.

    Medicare’s ACO programs so far have produced inconsistent results, some of which policy experts and ACO executives have blamed on how Medicare calculates how much ACOs potentially saved the program. Last week, the CMS announced that the initiatives saved Medicare $817 million through 2013. Dozens of participants shared $445 million of that amount, but three-quarters of ACOs saw nothing after failing to do sufficiently well against the financial benchmarks.

    Source: Melanie Evans
    Modern Healthcare [9/25/14]
    http://www.amazon.com/Accountable-Care-Organizations-Metrics-Formation/dp/1466581832/ref=sr_1_2?ie=UTF8&qid=1393959557&sr=8-2&keywords=cimasi

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  3. UnitedHealth’s $43 Billion Exit From Fee-For-Service Medicine

    Continuing the health insurance industry’s march further away from fee-for-service medicine, UnitedHealth Group UNH +0.81% (UNH) executives said that they will increase value-based payments to doctors and hospitals by 20 percent this year to “north of $43 billion.” UnitedHealth, considered a barometer for the health insurance industry given its size, is rapidly departing from the traditional fee-for-service approach that can lead to overtreatment and unnecessary medical tests and procedures. Value-based pay is tied to health outcomes, performance and quality of care provided.

    UnitedHealth’s pronouncements are in keeping with its previously stated commitment to increase payments that are tied to value-based arrangements to $65 billion by the end of 2018. Value-based payments come in a variety of forms. They include: pay-for-performance programs, patient-centered medical homes and accountable care organizations, a rapidly emerging care delivery system that rewards doctors and hospitals for working together to improve quality and rein in costs.

    Source: Bruce Japsen, Forbes

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  4. Accountable Care Organizations: The Numbers

    The consulting firm Oliver Wyman recently released research on the growth trends of accountable care organizations participating in Medicare’s ACO programs. Here are some key findings from the report:

    • There are an estimated 585 ACOs total in the U.S.
    • ACOs serve between 49 and 59 million U.S. residents, or between 15 and 17% of the population.
    • The number of ACOs rose by 12% last year and the number of patients served rose 6%.
    • 5.6 million Medicare beneficiaries (11% of total Medicare beneficiaries) receive their healthcare from ACOs.
    • ACOs provide care to 35 million non-Medicare patients.
    • Almost 70% of the U.S. population live in localities served by accountable care organizations.

    Source: Oliver Wyman, April 22, 2015
    http://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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  5. More Docs Are OK With ACOs

    Providers are more and more willing to participate in value-based care programs, according to a Dec. 9 roundtable of Blues plan executives at the Blue Cross and Blue Shield Association (BCBSA) in Washington, DC. While a “spectrum” of physician engagement still exists, one executive said he never thought he would see the day when so many doctors and insurers were actually excited about collaborating on accountable care.

    In October, BCBSA unveiled Blue Distinction Total Care, a nationwide network of accountable care programs for national employer clients, comprising 450 programs in 37 states. When insurers were attempting to launch the first accountable care organizations, some doctors were receptive to collaborating with insurers, while others weren’t. That dynamic still holds true today, but the tables are quickly turning.

    Source: Jane Anderson, AIS Health [January 2016]

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  6. ACOs

    We are currently working on developing some regional collaborative ACO strategies linking current and/or new ACOs to a larger provider base to increase assignments of beneficiaries as well as spread the administrative costs over a larger population. This gives us a unique perspective as to how the process of integration occurs and, when faced with an opportunity to buy in to an operating ACO, the schedule for integration advances quite quickly.

    We see three models. The first is a vestige of the older definition of integration where a lot of contracts between hospitals and physicians are exchanged and the newly formed provider unit attempts to leverage itself with third party managed care organizations to get higher fees. These structures eventually disappoint all concerned as the ability to reduce costs is exclusively tied to discounting fee schedules and not changing utilization patterns.

    The second model of Integration starts to get at the real issues of changing financial incentives of hospitals and physicians by creating new pathways for care and new workflows for administrative staff. Within this second model the focus is first on early intake, usually through primary care; the second is tracking and reviewing the physician to hospital admission hand off; and the third is the post discharge planning and return of the patient to a physician manager. Working at perfecting these three phases of care coordination usually produces some results.

    We are seeing shared savings contracts now being offered by larger employers as well as larger insurance companies. The only downfall here is lack of consistency because people get distracted by shiny objects. Meaning the big savings through reducing cost of the ESRD patients or a big savings of heading off hospital emergency room expenses overshadows the consistency needed in such areas as reducing unnecessary referrals and generally building a fully operational patient engagement process are set aside because of the big savings that occurs only a couple times in a performance period. To be successful the provider must do a lot of things consistently and we find that sometimes a simple workflow change can save more than all the big ticket items do.

    The third model gets at the core principles of not just clinical integration but also tying this to financial integration. This is where the dollars are usually coming in a bundled, global or capitated amount for one or more payers. Using the physician and hospital data they are able to track insurance claims and negotiate with the payer as a fully integrated care system. This last model is the jumping off point to a fully capitated, provider led health plan because it takes into consideration the total cost of care (TCOC) and connects it to select populations with a specific diagnosis. This is more than contracts or mere utilization changes; it is building consistency of incentives for physicians across an aligned set of goals.

    The hazard exists when a stage one contracted network attempts to join a risk bearing ACO network or build one on its own. Several large systems have spun their wheels, eventually calling in help to move them to stage three in a hurry so they could get their arms around all the pieces of the delivery system both inside and outside the four walls of the hospital or clinic to create a medical neighborhood with unified goals and guidelines. The collaboration model works because those early sponsored ACO can share their experiences and opportunity for change with less developed delivery systems.

    What has been missing all along is this definition of not just clinical integration but also financial integration. People have shied away from this, saying they do not want to take the risk. With all the new MACRA rules in effect and the hospitals being forced to follow Medicare instituted sanctions and incentives, the fact is that risk is here to stay and it’s moving more quickly than anyone had anticipated. The new model of the ACO is a shared risk and incentive plan that can be adopted across Medicare and commercial beneficiaries.

    William J DeMarco MA CMC
    [President/CEO, Pendulum HealthCare Development Corporation]

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  7. Emerging Healthcare Value-based Payment Models
    [The Role of Bundled Payments]

    The health insurance industry in the United States is on a collision course. Current costs and payment models are unsustainable. There are gaps in care and variation of quality. Current payment models reward providers for the number of procedures performed rather than for the quality of care provided.

    In fact, lower quality of care may result in higher payments when factors such as hospital readmissions are considered. Health Payers are looking for ways to change their focus from claims payment to being more involved in patient care. This includes focusing on wellness, care management and looking for ways to share the risks involved in payment for services. This has led to the emergence of value-based contracting models. Plans are working to drive business outcomes because evolving regulatory mandates and market conditions are creating both challenges and opportunities.

    This new paradigm is creating a demand for critical thinking and foresight. The successful plan will use both to create a new type of healthcare system.

    Source:
    Oracle, March 2016.

    Like

  8. Tim Gronniger: The 10 reasons accountable care organizations fail

    1. ACO does not have enough lives to take risk.
    2. Lack of training and process improvement.
    3. ACO has a lack of accountability and transparency.
    4. Ignoring behavioral and mental health.
    5. HCC coding is poor and inconsistent.
    6. ACOs don’t focus on managing patients better than the national fee-for-service average.
    7. Practices don’t have staff supporting population health.
    8. Clinicians can’t get data at the point of care.
    9. Doctors are not on board.
    10. The ACO cannot execute on quality improvement and reporting.

    Notes: Tim Gronniger is the Senior Vice President of Development and Strategy, Caravan Health
    Source: Becker’s Hospital Review, May 8, 2018

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