Accountable Care Organization Overview

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1 Accountable Care Organization Overview Presented by: Bill Wachs & Kai Tsai April 28, 2015

2 This webinar is brought to you by the American Hospital Association s Center for Healthcare Governance. Backed by the knowledge and resources of the AHA, the Center for Healthcare Governance provides state-of-the-art education, research, publications, tools, and other resources to help you achieve excellence throughout your governance program. Our community is dynamic and diverse, representing board members, executives, and governance advisors who are nationally recognized as the foremost voices in the practice of hospital and health system governance. We share a common goal to advocate and support excellence, innovation and accountability in health care governance. Learn more about the Center at Or contact us at (888) Valence Health. All rights reserved. 2

3 Webinar Agenda Speaker Introductions Commercial vs. Medicare ACOs ACO in the Spectrum of Value-Based Care Medicare Risk Options Questions for Discussion 2015 Valence Health. All rights reserved. 3

4 Speakers Bill Wachs Managing Director Valence Health Kai Tsai EVP Consulting Valence Health 2015 Valence Health. All rights reserved. 4

5 Webinar Agenda Speaker Introductions Commercial vs. Medicare ACOs ACO in the Spectrum of Value-Based Care Medicare Risk Options Questions for Discussion 2015 Valence Health. All rights reserved. 5

6 MSSP ACOs Have Requirements; A Commercial ACO Has Negotiations Commercial ACO MSSP ACO Legal and Governance Structure Structured to meet sponsor s needs Regulated by CMS; Governance shared by each ACO member entity Finance and Contracting Network Establish provider incentives through payment arrangements to promote efficient and effective care Market driven Bend the Cost Curve Defined Care Models to coordinate care Three Risk Tracks Options; Upside Only and two Upside/Downside Members can receive care outside of the network; reassigned based on where they receive care Quality Management Population Size Designed by provider or payer; focus on targeted initiatives No minimum size requirement Resources to manage risk Actively Manage Quality 37 Quality measures, including both pay for reporting and pay for performance Requires 5,000 lives 2015 Valence Health. All rights reserved. 6

7 Webinar Agenda Speaker Introductions Commercial vs. Medicare ACOs ACO in the Spectrum of Value-Based Care Medicare Risk Options Questions for Discussion 2015 Valence Health. All rights reserved. 7

8 Options for Different Levels on the Risk-Spectrum Value-based Risk Spectrum Increasing Risk FFS P4P PCMH CLINICAL INTEGRATION SHARED SAVINGS SHARED RISK CAPITATION FULL RISK HEALTH PLANS MSSP ACO Next Gen ACO Medicare Advantage CMS has announced its goal to shift 90% of all Medicare healthcare payments towards value-based models by Valence Health. All rights reserved. 8

9 Webinar Agenda Speaker Introductions Commercial vs. Medicare ACOs ACO in the Spectrum of Value-Based Care Medicare Risk Options Questions for Discussion 2015 Valence Health. All rights reserved. 9

10 Key Program Differentiators Feature MSSP ACO Next Generation ACO Medicare Advantage Network Open Open Closed or Controlled Attribution Retrospective Retrospective w/voluntary patient alignment option Enrolled assigned members Benchmark Historical expenditures Historical expenditures with regional trending Risk Adjustment Methodology Minimum Savings Rate or Discount Quality Program Upside/Downside Risk Retrospective for 3 year agreement MSR 2.0% - 3.9% based on attributed lives and selected track Metrics used to determined savings earned Track 1: 50% shared savings; 10% savings cap Track 2: 60% shared risk 15% savings cap Track 3: 75% shared risk 20% savings cap Retrospective adjusted annually with +/- 3% limits Discount of 0.5% to 4.5% Adjusted for regional and national efficiency MSSP Metrics determine discount to baseline (2-3%) 1) Years 1-3: 80% shared risk; Years 4-5: 85% shared risk 2) 100% risk for Parts A and B; option to build contracted network and pay claims 15% cap applies to both County based benchmarks tied to ACA payment quartiles Retrospective annually None Stars metrics drive ~5% bonus to benchmarks for 4+ Star rating 100% risk for Parts A and B No savings cap Payment Model Fee-for-Service FFS or Capitation Capitation Supplemental Benefits Minimum # Beneficiaries None 5,000 General: 10,000 Rural: 7,500 Beneficiary coordinated care reward $50 annually; other Various product enhancements available 5,000 in 3 years; waiver availability 2015 Valence Health. All rights reserved. 10

11 Webinar Agenda Speaker Introductions Commercial vs. Medicare ACOs ACO in the Spectrum of Value-Based Care Medicare Risk Options Questions for Discussion 2015 Valence Health. All rights reserved. 11

12 Post Webinar Board Discussion Questions 1. What does my Medicare patient base look like across FFS Original Medicare and FFS Medicare Advantage contracts? 2. Do I have enough Original Medicare patients to participate in MSSP or Next Generation ACO? 3. If you want to move to a risk based Medicare Advantage contract do you have competencies in the key factors for success including risk adjustment, Stars quality metrics, and care models unique to seniors? 2015 Valence Health. All rights reserved. 12

13 For More Information 2015 Valence Health. All rights reserved. 13

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