Posted in Accountable Care, ACO, Affordable Care Act

Center for Medicare and Medicaid Services Releases Accountable Care Organization Performance Results

by Gregg A. Masters, MPH

Friday, October 27th, the Center for Medicare and Medicaid Services (CMS) released details for participating Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) for the 2016 performance year.  For reporting ACO results view the entire report here.

The National Association of ACOs (NAACOs) weighed in below:

The new results demonstrate the value of a premier Medicare alternative payment model and include a higher rate (56 percent)* of MSSP ACOs generating savings than ever before and an almost equal proportion as last year of ACOs that earned shared savings (31 percent).

This public update follows previously posted results for Pioneer ACOs, the Next Generation ACO cohort and the Comprehensive End Stage Renal Disease ACO (ESRD) care model here.

In table form, the results are summarized below:

All in, participating ACOs generated $843 million in gross program savings with a modest net savings of $78.6 million for Medicare in 2016, in addition to material gains in quality scores for aligned ACO Medicare beneficiaries.

While Clif Gaus, NAACOS CEO notes:

These results show the growing success of ACOs, which is a positive trend that should not be ignored. A lot has been accomplished in a relatively short amount of time, and ACOs are on the front line of redesigning healthcare delivery. This is a moment to celebrate them and their hard work.

The ACO ‘Jury’ Is Still Is Out

Given the range of models, risk assumed or gain sharing distributed operating results in a program that some still see as fundamentally ill equipped in a predominant fee-for-services market to materially change physician and beneficiary behavior – and thus enable the elusive ‘triple aim‘ – many in the health policy area including select ACO operators remain convinced to maximize impact the ACO model will ultimately morph into the more robust Medicare Advantage operating platform.

Perhaps the ‘stealth play’ in the mix is the potential upside of Next Generation ACOs to fully leverage their competitive advantages (3 day SNF waiver, telehealth visits, relaxed supervision requirements for post hospital discharge visits and the move to all inclusive population based payments) can up-level both their game AND improve outcomes at lower per capita costs?

On the next episode of This Week in Accountable Care, our very special guest is former Acting Administrator of CMS Andy Slavitt, now Senior Advisor to the Bipartisan Policy Center. Andy was initially part of the ‘fix it dream team‘ that righted the failed launch of Healthcare.Gov, and then presided over the administration of the Affordable Care Act.

Andy is rather familiar with the original intent of the ACA, its many ‘working parts’ and the bumps in the road to perfect the law via provider input, updated rule making and policy refinements.

We’ll get Andy’s take on a range of issues from the political environment to conflicting health policy guidance including broad brush advice to ACO operators.

Join National ACO co-founders Andre Berger, MD and Alex Foxman, MD as we engage this visionary and accomplished entrepreneur turned public service official in critical dialogue impacting the transformation of our industry from its fee-for-services roots to a new model based on a value and patient centricity.

 

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Posted in Accountable Care, ACO, Affordable Care Act, Triple Aim

ACOs Fudging the Numbers?

by Gregg A. Masters, MPH

I came across this piece on the Healthcare Blog penned by Kip Sullivan, Esq, critiquing this article posted in Health Affairs last May ‘Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO‘. Sullivan raises valid points as the the legitimacy of claiming or inferring statistically insignificant results as a meaningful contribution of the subject ACO (a Partners Health sponsored venture) to ‘bending the cost curve’.

Sullivan un-bundles his argument effectively and raises issues for the industry writ large – including participating ACOs, their sponsors, the regulatory crew at both CMS and CMMI – and even the health policy press covering the sector.

I post the first few paragraphs of the piece below, for full reference the entire article on the Healthcare Blog is accessible via On the Ethics of Accountable Care Research‘.

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and ….

Comment

As someone who’s been in this dance since the mid 70s (PSROs, HSAs, HMOs, IPAs, PPOs, EPOs & all derivative plays) launched into Medicare risk via TEFRA (the Tax Equity and Fiscal Accountability Act) which introduced us to ‘Medicare Choice’ the for-runner of Medicare Advantage, I can say Sullivan’s critique of fully ‘burdening‘ ALL transformational efforts is rarely – if ever – factored into the volume to value pivot ‘investment calculus‘ of the effects of the intervention (in this case a Pioneer ACO) on the national spend.

It should be noted, the entire managed care industry can be assessed a gigantic collective FAIL for that matter as well. Since managed care penetrated ‘mainstream medicine‘ principally via extension of the HMO model typically on an IPA (independent practice association) chassis (vs. group or staff models) with the exception of a brief period in the 90s premiums continue their relentless upward march; while most payors continue to write commercial business only via an enterprise and industry wide cost shifting (risk transfer) charade. The tacit admission that there is no there there in the prevailing health insurance industry zeitgeist. They’ve proven they can NOT manage clinical risk, period.

So Kip, you might want to go a little lighter on those on the front lines trying to tame the ‘rapacious appetite’ of our ‘healthcare borg‘!

 

 

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

Webinar: Next Generation ACO Model – Overview and LOI Information

By Gregg A. Masters, MPH

Webinar: Next Generation ACO Model - Overview and LOI Information Select link to open options forShare
Click to register!

Today marks the end to the eight year reign of President Barack Obama and the birth of the Trump Administration tenure.  Yet, so much in the health policy and reform domain remains unclear and on the come.

Since the passage of the Affordable Care Act (ACA) in March of 2010 the implementation of the delivery system side of the reform to restrain if not reduce healthcare spending has been vested primarily in a range of variably sophisticated ACOs and other participants in a tapestry of value based healthcare arrangements from bundled payments to patient centered medical homes and even the more risk savvy cohort of Medicare Advantage operators.

What is clear is change is on the horizon; yet just what the nature of that change will look like will probably reveal itself over the next several months and perhaps even years. For our discussion of what appears to be the emerging indicia of a ‘TrumpCare‘ chassis, Health Innovation Media principals share insights via: ‘On @PopHealthWeek: #Trumpcare What We Know @fsgoldstein @efuturist @2healthguru‘ and ‘A #TrumpCare Roundtable with @efuturist, @fsgoldstein and @2healthguru‘.

screen-shot-2017-01-20-at-1-52-24-pmClearly the era of ‘accountable care‘ and the provider organizations designed to explore and implement their local market vision of an entity that delivers accountability is not likely to come to an end as President Trump occupies the White House. In fact, though I have been deeply skeptical of the rather hollow ‘repeal and replace‘ mantra absent a material Republican replacement option, I am somewhat encouraged by the tempered optimism proffered by Ezekiel Emanuel, M.D., Ph.D., Former Chief Health Policy Advisor to the Obama Administration, to an informed audience at the Commonwealth Club of San Francisco earlier this month.

Meanwhile, I doubt the Trump Administration and his HHS and CMS appointees (Rep Tom Price and Seema Verma, respectively) once confirmed will advocate for an era of ‘unaccountable care‘ with a return to unbridled to fee-for-services medicine. Thus, I bank on the continued evolution and deployment of ACOs as progressive risk bearing entities and continuing clinical integration plays. However, we shall see!

We do indeed live in interesting times!

 

 

 

Posted in Accountable Care, ACO, Affordable Care Act

The NextGen ACO: Another Round Opens

by Gregg A. Masters, MPH

The Centers for Medicare and Medicaid Innovation has announced the results of its ‘continuous learning‘ commitment model wherein ‘field reports‘ including provider comments and open door inputs are materially incorporated into tweaks of the Medicare Shared Savings Program (MSSP) as risk is progressively adopted by participating ACOs. This ‘new round’ iteration no doubt includes ‘lessons learned‘ from the Pioneer ACO Program including the many ‘exits’ and risk downgrades opted to date.

In summary, this round is:

‘..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.’

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For complete information, see: ‘Next Generation ACO Model | Center for Medicare & Medicaid Innovation‘.

 

 

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

The Droids You Are Looking For Are Not Here

by Gregg A. Masters, MPH

Beneath the ideological crossfire and mostly bluster of the ACA ‘repeal and replace crowd’, while the latest ‘new, new, thing‘ aka the defacto Rorschach upside of a litany of mostly vaporware or me too ‘meh‘ digital health apps, platforms or S-1 filings (see: ‘Disruptive Idiots from Silicon Valley‘) stumble into maturity amidst growing calls for validation and evidence of tangible ecosystem sustainability, a pulse of innovation can be found in some less ‘sexy’ sectors.

Some time ago physician innovation pioneer Richard Merkin, MD, the founder and principal visionary behind the Heritage Provider Network and all of its sequelae (Heritage Medical Systems, Heritage ACO, etc.), opined from the stage at the ACO Summit that perhaps the biggest contribution (gold) from the ACA was to be mined from the forward leaning work stimulated by the law’s enablement of the Centers for Medicare and Medicaid Innovation (CMMI) aka @CMSinnovates on twitter.

Richard Gilfillan MDThe indisputable driver of what was then invested in Richard Gillfilan, MD the first CMMI Director (now stewarding the transformation at Trinity Health System, @TrinityHealthMI), was the volume to value imperative.

Into this challenge was cast considerable public capital/incentive funds to model what that meant from a delivery system and financing re-engineering perspective. Perhaps fueling the discounting of CMMI’s early efforts was the poorly constructed ‘Pioneer ACO‘ program, ostensibly designed to attract a more risk savvy pool of players who could reasonably assume greater risk and therefore earn more meaningful bonuses for doing what they already know how to do principally via Medicare Advantage participation. This early cohort of 32 ‘Pioneers’ has dwindled recently to 19 with the recent defection of the trophy Darmouth-Hitchcock ACO, see:Dartmouth-Hitchcock exits Medicare’s Pioneer ACO program‘.

With that as backdrop, consider the following timely guide from the Cooperative of American Physicians titled ‘The Physician’s Guide To Value-Based Compensation‘. Consider this an essential ‘blocking and tackling’ primer of how to incentivize the granular behavior of those who write the ‘purchase orders’ for an essentially supply driven healthcare economy. As my colleague and surfing buddy John Mattison, MD (@JohneMattison), Assistant Medical Director, and CMIO Kaiser Permanente Southern California (@KPshare) often says: ‘we get what we incent’.

CAP_guide to value based comp

[Editor’s Note: and for those of you really interested in where the AMA stands on the bridging the volume-to-value divide, listen to: Health 2.0 Fall Conference 2015: An AMA Deep Dive on ‘The App Cure’].

Whether the ACA is repealed (highly doubtful) or materially modified (also not likely) its essence will not and cannot be ‘undone’ – the horse is out of the barn. Like it or not, the controlling DNA driving the many moving parts articulated in the ACA (and its state lab version ‘RomneyCare’) builds on decades of established health policy thinking on what works in the uniquely American public/private pluralistic partnership of healthcare financing and delivery.

Watch the ‘enablers’

Whether ACOs, fully integrated delivery systems (real IDNs – NOT their IDN lite versions), PCMHs, or one of a number of strains of risk bearing organizations (RBOs) from bundled pricing to full blown per member per month (PMPM) capitation, this is where the sustainable action can and will be found. This other stuff, plays well at CES and the many wannabe healthcare industry copy cat conferences playing an up the ante ‘cool factor’ card to an often ADD crowd, yet it’s tangible contribution to the triple aim or sustainable healthcare economy remains squarely ‘on the come.

 

 

Posted in Accountable Care, ACO, Affordable Care Act

Courtesy of our friends at AJMC: ‘5 Things to Know About Accountable Care Organizations’

by Laura Joszt

This week, The American Journal of Managed Care was in Palm Harbor, Florida, hosting the fall live meeting of its ACO and Emerging Healthcare Delivery Coalition, where stakeholders from across the healthcare industry discussed best practices. As the country moves from volume to value, accountable care organizations (ACOs) can play a key role during the transition from fee-for-service. However, ACOs not only remain largely a mystery to the average consumer, but also to providers who may be part of an organization participating in an ACO. Here’s what you need to know about ACOs:

1. ACOs are older than the Affordable Care Act. At least, the theory of ACOs is older. While the inclusion of ACOs in the health reform law has accelerated adoption of the delivery model, the term “accountable care organization” was first coined in 2006 by Elliott Fisher, MD, director of the Dartmouth Institute for Health Policy and Clinical Practice.

2. There are multiple models established by CMS. There are a number of different ACO models being offered by CMS. The most common model is the Medicare Shared Savings Program (MSSP), which has 404 ACOs and is accepting more. The Pioneer ACO Model is for healthcare organizations and providers already experienced in coordinating care, and while it started with 32 ACOs, just 19 remain today. The Advance Payment ACO Model is designed for physician-based and rural providers. And the newest model is the Next Generation ACO, which takes on greater performance risk with potentially greater rewards. The Next Generation ACO model is….

Complete article by Laura Joszt posted here.