Accountable Care Organizations

DanielMcCabeMDArizonaConnected Care

Tucson, AZ

• Accountable Care Organizations arose from the AffordableCare Act

• A group of doctors, hospitals, and other health care providers who work together to provide the patient with better, morecoordinated care by sharing data and resources

• The providers are responsible and accountable for quality, patient satisfaction, and keeping global costs down across thefull spectrum of care

• Majority of shared savings will go back to primary careand much of it will be reinvested in care programs

Accountable Care Organization(ACO)

Where the Medicare ACOsAre9 Pioneer, 433 Shared Savings Program, and 20 Next Generation ACOs1

as of April 2016

Why do we need this new approach?

§ Healthcare costs too much

§ It doesn’t do a good job

§ The system is “broken”

§ Current system is still geared to:“The more you do, the more you make”

Patients are unhappy

Low expectations§ Can’t find a doctor/provider§ Long waits

§ Can’t be seen when they need to be§ High Deducible plans increasing

“I have the best doctor in the world, but I have to waithours to see him.”

Foundational Principles

Don Berwick and the Triple Aim:

§ Improve the patient experience

§ Improve the health of the population

§ Reduce the per capita cost of health care

Can all three be accomplished at the same time?

Arizona Connected Careproposes to do just that!

We are a payment-reformand

delivery-reform model …

Why did AzCC choose to be anACO?

§ Focus is on wellness and prevention along with chronicdisease management

§ Care coordination helps at-risk patients avoid unnecessary hospital readmissions

§ Providers must meet quality measures, patientsatisfaction standards while keeping costs down acrossthe full spectrum of care

§ Majority of shared savings will go back to primary care- and much of it will be reinvested in care programs

Contractual Quality Measures• MSSP

33 GPRO measures- 4 domains:• Patient/Caregiver Experience• Care Coordination/Patient safety• Preventative health• Clinical Care for at-risk population

• UHC Medicare Advantage• 4 Core measures• 8 HEDIS quality measures (changed for 2017)• Resource Funding• Efficiency Based

• Cigna Commercial• 18 measures

• United Commercial• 15 measures

Efficiency Metrics

• Admits per 1000• Re Admits per 1000 (not %)• SNF admits per 1000• ER visits per 1000• Specialists visits per 1000• Total Cost of Care per member• Variation Analysis in selected areas

Investment and Risk

• Primary Care has the largest burden• Significant startup time and capitol• Savings occur 6-9 months after year

end (delayed cash flow)

• Types of risk -one vs. two sided• Collared risk as an alternative• Reserves (Hurricanes)

Shared Savings

• Range up to 70%, as low as 10%, most 50\50

• Modified up\down by qualityperformance

• Based on Total Cost of Care vs. Budget• Budget based on patient attribution

and benchmarked financial costs

Medicare Shared Savings ProgramMSSP

• Need 5,000 lives minimum, apply July for the next year• Historical Attribution Model based on claims• Two step attribution model, PCP and specialists• Based on 3 prior years of expense• National increment• Given a PMPM budget (preliminary), quarterly

reports• 3-6 months after year end CMS does reconciliation

MIPS vs. eAPM’s

Proposed Rule released spring 2016

MIPS in FFS

• 2017 work product influences 2019payment

• Based on Quality, Cost, EMR, and Ancillary

• 1.0 Composite Score graded on the curve• Starts at +\- 4% growing to +\- 9%• CMS budget neutral.• Win Lose proposition

Cost’s of MIPS in FFS

• Estimate of 400-800 staff hours per MD• $11,000 to $30,000 per year per MD

• Chance of scoring 1.0 (average) is 35-40%• If bonus\claw back is done by a Bell curve

• In 2019, 2% bonus has a 17% chance ofsuccess

4% bonus has a 2.5% chance

APM’s with risk

• MSSP track 2 and 3, NexGen ACO• Excluded from MIPS• GPRO reporting continues• Must meet eligibility requirements• Potential 5% bonus (FFS) vs risk of

capitiation

Cost of eligible APM’s (e-APM’s)

• GPRO - Estimate 10-40 staff hours perMD

• $300 to $16,000 per year per MD

• Cost of ACO per PCP MD per Year percontract $2,000.00 without shared savings.

• Range is $300 to $18,000

The Hybrid MIPS-APM• CMS writing new legislation for MACRA• Designed for Track 1 MSSP and non qualifying

APM’s• BPCI excluded in proposed rule• Preferential scoring is given in MIPS• Estimates $500 million (6 yrs) set asides for

Composite Scoring (33 quality measures)• All pending the Final Rule from CMS in the fall

MSSP Track 1.5

• No proposed legislation for Track 1 MSSP

• Camel’s nose is inside the tent.• Consistency of risk is key for eligibility

• Solution maybe collared downside risk(4%)

• Two step process for PCP’s

APMs vs. CINsAPMs and PCPs

• ACO-based Model• 30% bonus over 6 years• No MIPS, just GPRO• Better for PCP’s• Population based• Risk based• Less anti-trust risk• Profits shared with MDs

• CINS and MIPS

• Specialists-hospital model• 2% raise over 4 years• Burdensome MIPS reporting• FFS based; no utilization focus*• Specialist high cost focus• More paperwork and hoops• Hospital keeps all the money• Takes no risk• •No category 3 and 4 payments• For PPO insurance products• Business as usual !!!!!

*no metrics around inappropriate care

Questions