Posted in Accountable Care, health innovation challenges, health insurance reform, MSSP, Triple Aim

The Next Generation ACO: Accelerating the Transformation from Volume to Value

In January 2015, then Secretary of Health and Human Services (HHS), Sylvia Burwell outlined ‘Federal policy‘ and for the first time put a measurable stake in the ground to scale the pivot from fee-for-service to value based healthcare with concrete milestones and an associated timeline. The policy outlined seemingly scalable goals via linking 30% of traditional fee-for-service Medicare payments to quality or value through ‘alternative payment models‘ (APMs) including Patient Centered Medical Homes (PCMHs), ACOs or ‘bundled payment arrangements‘ (BPHCI) year end 2016, scaled up to 50% of payments year end 2018. For details see: ‘HHS Sets Specific Targets and Timelines for Alternative Payment Models and Value-Based Payment‘.

Now fast forward to 2017. First introduced in 2016 we’re approaching the start date of a ‘new and improved‘ ACO tagged the ‘next generation ACO model‘ now embracing an ‘all in population based payment‘ (AIPBP) option that ZERO’s out fee-for-service payments.

Between ACO operating results, significant provider community feedback via several Notice of Proposed Regulations‘ (NPRMs) and what some may say is simple commonsense, this latest iteration of the Next Generation ACO model is looking more and more like their predecessor risk bearing operators in the 80s and 90s.

As CMS notes:

Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program (Shared Savings Program), the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients. It will allow these provider groups to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

The Bottom Line

We (i.e., ACO industry operators, associated management companies’ including venture financiers, CMS and supplier stakeholders) are tweaking the ACO formula via a range of models that materially engage the provider AND payor communities as co-creators of a sustainable healthcare ecosystem embracing value and outcomes as the ‘dependent variable’.

With the uncertainty surrounding the future of the ACA and it’s likely ‘Trumpcare’ or ‘RyanCare’ replacement options, some argue ACOs are in an unspoken ‘safe harbor’ of sorts. Yet, much detail remains to be added before that picture is functionally revealed. Here at ACO Watch we’re proceeding on the assumption that ACOs or the accountable care industry collectively, are not likely to disappear anytime soon. So we’re posting some resources below:

For a deep dive into the AIPBP option CMS is hosting an Open Door Forum: Next Generation ACO Model – Overview of Population-Based Payments on Tuesday, April 11, 2017 from 4:00PM – 5:00 P.M. EDT.

For those pondering their 2018 ACO participation options, CMS‘s Center for Medicare and Medicaid Innovation (CMMI) issued an RFA (request for applications) and activated the application portal here.  

Finally to complete the picture CMS is hosting a series of open forums to provide an overview into the Next Generation ACO model offering information on the required letter of intent and on-boarding process in general on these dates as follows:

  • March 14 from 4 – 5 pm ET — Application Overview and Participating Provider Lists
  • March 28 from 3 – 4 pm ET — Benefit Enhancements Overview
  • April 11 from 4 – 5 pm ET — Overview of Population-Based Payments & All-Inclusive Population-Based Payments;and
  • April 15 — Deep Dive: Completing Your Next Generation ACO Model Participant List

For the complete list of available CMS ACO resources, click here.

And finally for those who desire an overview of the ACO theater, check out the dated but informative: ‘Accountable Care Organization (ACO) 101: A Brief Course by Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs, American College of Physicians (ACP).

 

 

 

Posted in Accountable Care, ACO, Affordable Care Act, MSSP

Final Medicare Shared Savings Program Rule (CMS-1644-F)

by Gregg A. Masters, MPH

Creating consistent high quality original content is hard. At ACO Watch, we’re not in the business of breaking news or high frequency posts to drive eyeballs and traffic to this blog so ‘the numbers’ that might attract advertising or sponsorship (there aren’t any). Instead we (mostly me) watch the developments in the sector and offer newsworthy items now and then with some commentary which usually tethers to institutional memory (often failure, some successes) of having been in this dance for a while.cms final rule MSSP

So here’s the latest from CMS on the proposed final rule for ACOs participating in the Medicare Shared Savings Program, see published rule here.

I remember back in the day when CMS was known as HCFA (the Health Care Financing Administration) and inside the Baltimore HHS complex, there dwelled an office with the name ‘Alternative Delivery Systems’ (ADS). This was the locus of staff (very modest at that time) tasked to monitor and track what was then limited to HMOs and the newly minted though ‘lite version’ dubbed PPOs.

Fast forward some 45+ years and those ‘alternative entities’ have become mainstream so to speak. Literally all benefit plans written today are contractually delivered via participating providers (IPAs, PHOs, IDNs, health systems, alliances, networks, direct or more recently ACOs) are some form of ‘managed care’ unless those providers have opted out of Medicare, Medicaid and commercial insurance in favor of Direct Practice or worse ‘Concierge Medicine’.

Since the Secretary of Health and Human Services has recently set a goal to have Medicare move away from its traditional reliance of unbridled fee-for-services medicine to a range of what CMS has or will define as ‘value based care‘ arrangements – everything from bundled payments, to gain sharing, to partial or global risk assumption by providers (hospitals, health systems, IPAs or ACOs (the next generation) much attention has focused on the right combination of incentives, infrastructure and regulatory context to move this historically change resistant healthcare delivery ecosystem into the brave new world of value vs. volume.

This is the latest effort by CMS to tweak the ACOs regs in order to meet some of the persistent objections to the program while scalably incentivizing the essential journey to risk assumption by providers is noted as:

The policies adopted in this final rule are designed to strengthen incentives in order to continue broad-based program participation and improve program function and transparency.

While the broader context is summarized as:

On June 6, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to incorporate regional fee-for-service (FFS) expenditures into the methodology for establishing, adjusting, and updating the benchmarks of Accountable Care Organizations (ACOs) that continue their participation in the Medicare Shared Savings Program (Shared Savings Program) after an initial three-year agreement period. This final rule also adds a participation option to encourage ACOs to transition to performance-based risk arrangements and provides greater administrative finality around the program’s financial calculations. CMS is making these modifications to strengthen incentives under the program after considering comments received on issues specified in the 2016 notice of proposed rulemaking. 

There is more to the story, and the referenced PR is here.

 

 

Posted in Accountable Care, ACO, Affordable Care Act, health reform, MSSP

An ACO ‘Shell Game?’ Of Arrows, Pioneers & Patsies’

By Gregg A. Masters, MPH

In ‘Pioneers Take Arrows While Settlers’ Get the Land’ I reported in a ‘just the facts ma’am’ fashion the developing narrative as proferred by Modern Healthcare, CMS, and the AMGA as to whether this was to be seen as good news or bad news.

Pioneer with arrow in backRecently the witty industry veteran and futurist  Ian Morrison weighed in via ‘Why Some ACO Pioneers Turned Back, as did Oliver Wyman via ‘The Year of the Pioneers’ and even the health policy braintrust, aka the ‘…aw shucks, we just really want to help Obamacare out’ cheerleading squad at the American Enterprise Institute weighed in via ‘Reforming Medicare integrated care: An alternative to the Obama administration’s accountable care organizations. Whoa can you say bandwidth consumption?

Indeed, rather than parse out each, I will address them separately via individual consideration. I just wanted to get them on the blog before more time passed.

I might add that as far back at June of 2012 at the jointly sponsored CAPG (California Association of Physician Groups) and IHA (Integrated Healthcare Association) ACO Congress word on the streeet had it  ‘all was not well in Pioneer land’. So fresh as some of these insights and realization may claim to be, some of the more chronic challenges have been on the record for quite some time.

You  might enjoy the reading ‘From ‘Unicorns to Multicorns” ACOs Morphing Below Radar’ which followed the ACO Congress.

As some say….

More will be revealed

Posted in Accountable Care, ACO, Affordable Care Act, MSSP

‘Pioneers Take Arrows While Settlers’ Get the Land?’

At the ACO Summit in Washington DC in June 2012 Elliott Fisher, MD arguably one of the admitted father’s of the ACO movement opined perhaps prophetically from a panel including Mark McClellan, MD and former Health Affairs Editor, now RWJF Senior Health Policy Advisor Susan Dentzer the above wisdom.Richard Gilfillan MD

Today, CMS via the Center for Medicare and Medicaid Innovation (CMMI) released their eagerly anticipated results for the Pioneer class, i.e., that risk savvy group of participants most likely to make the accountable care vision work. Unfortunately as was the case in the predecessor Physician Group Practice (PGP) demonstration sample, the results where well ‘mixed’ with several exiting the program entirely while other’s chose to default to the ‘tamer’ Medicare Shared Savings Program.

According to Modern Physician:

Seven Medicare Pioneer accountable care organizations that didn’t produce savings in the first year of the Obama administration’s most ambitious test of the accountable care model have told the CMS they will leave the Pioneer program and enter the Medicare Shared Savings Program model, while another two participants have indicated they will leave Medicare accountable care entirely, the federal agency announced Tuesday.

The American Medical Group Association (AMGA) also released the following statement:

…regarding the announcement from the Centers for Medicare & Medicaid Services (CMS) on first-year results from the Center for Medicare and Medicaid Innovation’s Pioneer ACO Program (25 of the 32 health systems in the program are AMGA members):

“AMGA member groups are in the forefront of transforming the nation’s healthcare delivery system to achieve coordinated, affordable, high-quality care. AMGA is always proud to highlight the groundbreaking and innovative steps our members have taken, and continue to take, in order to improve the quality of our nation’s healthcare system, but today we are particularly pleased to congratulate members in the Pioneer ACO program for improving patient care and in some cases lowering the cost of care. All of these groups are to be applauded for their leap of faith and their continued dedication to advancing the role of high-performing health systems in America. ”

As with any ambitious effort of this scale, the movement to value-based, accountable, coordinated care for patients is an evolutionary process. Programs like ACO initiatives will take many years to mature, especially because they are creating and testing new models for payment and care delivery. AMGA is encouraged by the achievements of the Pioneer ACO participants in the first year of the program. We also pledge our continued support of our members that are committed to promoting better health care at lower costs in the Pioneer ACO and Medicare Shared Savings programs. ”

Many AMGA medical groups, and in particular the ACO Pioneers, are laying the foundation for future programs and innovative payment arrangements. These medical groups will continue to invest in improvements in care processes and infrastructure that will provide patients with better health outcomes, enhanced care experience, and lower costs well into the future. AMGA commends all of our members who have undertaken this journey. – Donald W. Fisher, Ph.D., CAE, AMGA President and Chief Executive Officer

The CMMI announcement reads in part as follows:

Today, the Centers for Medicare & Medicaid Services (CMS) announced positive and promising results from the first performance year of the Pioneer Accountable Care Organization (ACO) Model, including both higher quality care and lower Medicare expenditures. Made possible by the Affordable Care Act, the Pioneer ACO Model encourages providers and caregivers to deliver more coordinated care for Medicare beneficiaries. This model, launched by the CMS Innovation Center, is part of the Affordable Care Act’s efforts to realign payment incentives, promoting high quality, efficient care for Medicare beneficiaries. ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely.

“These results show that successful Pioneer ACOs have reduced costs for Medicare and improved the quality of care for their patients,” said CMS Administrator Marilyn Tavenner. “The Affordable Care Act has given us a wide range of tools to realign payment incentives in Medicare and Medicaid, and these efforts are already paying off.”

For the complete CMMI announcement with exit rational and implications for the program, click here.

Posted in Accountable Care, ACO, MSSP

Day 2 4th National ACO Summit

By Gregg A. Masters, MPH

Year four for the annual DC gathering of the best and brightest minds in the ACO space, convened yesterday in pre-conference sessions at the Hyatt Regency, DC. Day 2 kicks off with a keynote by Senator Ron Wyden @RonWyden, followed by a power packed tour de force of ACO operatives:

Opening Panel 4th National ACO
Complete agenda and schedule is available here.

Yesterday was a light ‘twitterstream’ but analytics are here and the transcript is here.

Posted in Accountable Care, ACO, MSSP

The 4th National ACO Summit

By Gregg A. Masters, MPH

Following two days of the Bundled Payment and Healthcare Innovation Summits, Wednesday June 11th kicks off the pre-conference sessions for the 4th National ACO Summit.

4th National ACO SummitThe program is packed with health policy wonks, clinicians on the leading if not bleeding edge of the movement, as well as consultants, lawyers and a constellation of other stakeholders watching, participating or aspiring entry into the reinvention of healthcare delivery, finance and organization.

After all, if not ACOs what’s next, single payor? So literally, ‘it’s showtime..’. Either innovative public/private partnerships play out as envisioned by Don Berwick’s triple aim, or game over.

A complete program schedule is available here. The summit is a hybrid session both in person and via the web. There is still time to participate remotely by registering here.

We’ll be interviewing some of the leaders presenting at the Summit and will post them here and on Health Innovation TV shortly.

The hashtag for the Summit is #ACOsummit. To follow the tweets checkout the @symplur registered digital dashboard. Ping me if you’re on site and want to get on camera.

Posted in Accountable Care, ACO, MSSP

Busy Week in DC

By Gregg A. Masters, MPH

Last week it was xx in health, followed by the Health Datapalooza and winding down at Medcity News Engage: Unlocking Patient Engagement Through Innovation where I moderated the panel: ‘Patient Engagement in An ACO World‘:

This week it’s back to back sessions beginning Monday, June 10th at the National Bundled Payment Summit, followed by the National Healthcare Innovation Summit and concluding with the 4th National ACO Summit.

In this morning’s session I was struck by Andrew Osterman of The Advisory Board admonition suggesting the Bundled Payment Care Improvement (BPCI) may be a more suitable gateway drug into the ACO theater than the MSSP. Osterman suggested the MSSP financial incentives were probably not the most effective means to attract participation in the program at least from a hospital’s ‘lost revenue’ opportunity perspective that would likely not be offset by a 50% gain sharing arrangement with CMS.

But the line that really captured my attention as this speaks to the underlying schizophrenia between health policy and law via the Affordable Care Act and present day volume based financial incentives:

Success in risk based contracts requires hospitals to understand their volumes through the lens of episodes of care. Today, hospitals’ have no incentives to create systems which can analyze what care falls within an episode of care

There is more to come, so stay tuned!

For the complete set of CMS innovation including the four models of Bundled Payment program, click here.