AIM: A Medicare ACO for Rural Providers. Federal Office of Rural Health Policy April 2, ACO Investment Model

Transcription

1 AIM: A Medicare ACO for Rural Providers Federal Office of Rural Health Policy April 2, 2015 ACO Investment Model Stephen Jenkins, Model Lead April 2 nd,

2 Opportunity The business case for an ACO requires a long investment horizon Starting and sustaining an ACO is expensive and risky Shared savings potentially offset investment costs over a long period of time which creates a barrier to model entry ACOs may lack capital needed to enter Medicare ACO programs/models and sustain participation ACO concerns regarding cash flow and ability to endure through the ACO transformation 3 ACO Investment Model The ACO Investment Model provides pre-paid shared savings to ACOs for staffing and infrastructure that supports population care management, financial management or other essential ACO functions. November 6,

3 Upfront Y2M12 Y2M11 Y2M10 Y2M9 Y2M8 Y2M7 Y2M6 Y2M5 Y2M4 Y2M3 Y2M2 Y2M1 Y1M12 Y1M11 Y1M10 Y1M9 Y1M8 Y1M7 Y1M6 Y1M5 Y1M4 Y1M3 Y1M2 Monthly Total Y1M2 Upfront Y1M3 Y1M4 Y1M9 Y1M8 Y1M7 Y1M6 Y1M5 Y1M12 Y1M11 Y1M10 Y2M1 Y2M2 Y2M3 Y2M4 Y2M5 Y2M6 Y2M7 Y2M8 Y2M9 Y2M12 Y2M11 Y2M10 Monthly Total ACO Investment Model ACO Investment Model (AIM) tests two effects of pre-paid shared savings Test 1: Whether and how pre-paying a portion of expected shared savings to ACOs increases ACO participation in MSSP, especially how encouraging participation in rural areas or areas of low ACO penetration may spur new markets to focus on improving care outcomes for Medicare beneficiaries. Test 2: Whether pre-payments encourage existing Medicare ACOs to select payment arrangements with higher levels of financial risk. Encouraging ACOs to transition to higher risk arrangements may also thereby increase the degree and speed at which ACOs can improve care for beneficiaries and generate Medicare savings. 5 Payment to ACOs Test 1: 2016 MSSP Starter ACOs (Example chart of ACO w/ 7,000 beneficiaries, $000s) 1,846 (100%) Upfront funding: $250,000 lump sum + $36 per beneficiary Monthly funding: $8 PBPM (up to 24 months) 558 (30%) 1,288 (70%) Test 2: Existing ACOs (Example chart of ACO w/ 7,000 beneficiaries, $000s) Upfront funding: $36 per beneficiary Monthly funding: $6 PBPM (up to 24 months) 294 (23%) 966 (77%) 1,260 (100%) 3

4 Eligibility Test 1 (New MSSP Starters in Test 2 (Existing ACOs) 2016) ACO start date MSSP 2016 MSSP 2012, 2013, 2014 (at least one year of reconciliation) Size 10,000 or fewer aligned beneficiaries Provider-based with exception of ACOs containing Critical Access Hospitals (CAHs) or small IPPS hospitals (100 beds or fewer) Prior ACO performance None Successfully report quality measures Other Not owned by a health plan Did not participate in the Advance Payment Model 7 Selection Criteria Test 1 (New MSSP Starters in 2016) Test 2 (Existing ACOs) ACO penetration (preference for lower penetration) Included (4 points) NOT Included Rural Location Included (4 points) NOT Included Movement to higher risk track/ Retention Demonstration of need (i.e. needs statement) Included (2 points) Included (6 points) Included (2 points) Included (2 points) Quality of Spend Plan Included (8 points) Included (8 points) Financial NOT included Included (2 points) Quality measures NOT included Included (2 points) 8 4

5 Recoupment from ACOs Repayment (if ongoing Medicare ACO participation) Repayment (upon terminating participation as Medicare ACO) Test 1: 2016 MSSP starters Test 2: Existing ACOs Repay out of earliest available net shared savings dollars in current and/or future agreement periods if necessary Require repayment of balance in full only if ACO terminates participation within initial agreement period (balance is forgiven if ACO decides not to reenroll in a future agreement period) Remaining balance to be repaid in full in all cases (i.e. upon termination within initial agreement period OR upon termination or non-reenrollment as an ACO at any future date) IF a 2016 MSSP starter (Test 1) has not had sufficient shared savings to payback AIM funds AND did not terminate within the initial agreement period, THEN that ACO will not repay its remaining AIM balance if it terminates at that point In all other situations, the ACO will repay the full AIM amount 2016 MSSP starter with sufficient shared savings 2016 MSSP starter that terminates within initial agreement period Existing ACOs in all cases 9 Timetable Date October 15, 2014 October 15, 2014 December 2014 April 2015 June 2015 July 2015 January 2016 Activity / Milestone Program Announcement Test 2 (2012 and 2013 Starters) Application released Round 1 applications received for ACO Investment Model Begin disbursements of upfront and monthly payments for Round 1 AIM ACOs Round 2 (2014 and 2016) Application released Round 2 Applications received Begin disbursements of upfront and monthly payments for Round 2 AIM ACOs 10 5

6 Additional Information Please Visit our Website at: Investment-Model/ us at Aim ACO Webinar FORHP April 2, 2015 A. Clinton MacKinney, MD, MS Clinical Associate Professor and Deputy Director RUPRI Center for Rural Health Policy Analysis University of Iowa College of Public Health 6

7 13 ACOs a keystone of alternative payment models (APMs) Accountable Care Organizations Bundled payments Patient-Centered Medical Homes Shared savings plans a better descriptor Already rapidly expanding HHS announcement likely to accelerate ACO development Clint MacKinney, MD, MS 14 The house always wins. (Lynn Barr) To obtain utilization and service location data To learn Population health management Financial risk management To prepare for population-based payment (capitation) Leverage the payment dollar For some, FFS/CBR may be unsustainable Clint MacKinney, MD, MS 7

8 15 Commonwealth Fund study of projected ACO core components and 42 associated capabilities People-centered care Health homes High value network Payer partnership Population health data management ACO leadership Source: Kroch, E. et al. Measuring progress toward accountable care. Premier Research Institute. December Clint MacKinney, MD, MS 16 RUPRI Established clinically integrated health system Tight physician engagement Population health and risk management experience Yet these are strengths that can be learned Witness NRACO Consortium Current MSSP and new ACO Investment Model allows relatively low risk learning Clint MacKinney, MD, MS 8

9 17 What is the prior experience? How are rural needs considered? Who decides (governance)? How are investments prioritized? How are potential savings shared? What value do you bring? What is your capacity for investment? Who fulfills CMS requirements? How does an ACO fulfill your mission? Clint MacKinney, MD, MS 18 Currently ACO v1.0 Training wheels Tweaking and improving; e.g., ACO Investment Model and Next Generation ACOs But more dramatic change coming with Accountable Care Communities Blends health and human services care delivery, payment, and governance Begins to address social determinants of health Clint MacKinney, MD, MS 9

10 19 Vision To build a knowledge base through research, practice, and collaboration that helps create high performance rural health systems 3-year HRSA Cooperative Agreement Partners RUPRI Center for Rural Health Policy Analysis Stratis Health Support from Stroudwater Associates, WIPFLI, Premier, and Washington University Check out tools/resources at Clint MacKinney, MD, MS Case studies of four ACOs active in rural counties One each of the four census regions Survey of 27 ACOs active in rural counties Keith Mueller, PhD 10

11 Previous organizational integration among local healthcare organizations: multispecialty clinic in a PHO; 2 hospital systems and medical staff; physician IPA and hospital systems Risk-sharing experience: with Medicare Advantage, owning their own insurance plan Keith Mueller, PhD Information technology: in all four sites providers shared the same EHR; telehealth capabilities in three sites Strategic partnerships: with local employers and business leaders, with human service organizations, with healthcare providers not part of ACO structure (e.g., long term support services) Keith Mueller, PhD 11

12 Step toward value-driven rural delivery system, with or without ROI for this specific venture Strategies to increase value: care management, post-acute care redesign, medication management, end-of-life care planning Keith Mueller, PhD Sixteen rural ACOs were formed by pre-existing integrated delivery networks. Physician groups played a more prominent role than other participant types (including solo-practice physicians) in the formation and management of these rural ACOs. Keith Mueller, PhD 12

13 Thirteen rural ACOs included hospitals with quality-based payment experience, and 11 rural ACOs included hospitals with risk-sharing experience. Twelve rural ACOs included physician groups with both qualitybased payment and risk-sharing experience. Managing care across the continuum and meeting quality standards were most frequently considered by respondents to be very important to the success of rural ACOs. Keith Mueller, PhD Pathway to Sustainability Lynn Barr, MPH

14 Who is the Consortium? First ACO created by nine rural CEOs in three states. Currently operating six ACO s in nine states. Now setting up 41 state-wide Rural ACO s in 2016 Our goal is to increase profits, market share and sustainability of rural health systems who manage population health to gain more of the premium dollar. 27 Do You Want to be the Chef or the Lunch? 10,000 lives = $80 million in healthcare spending by your community. Payor profit is LIMITED to $12 million. You are lucky to make $500K. 14

15 Path to Sustainability Actuarial analysis PCMH Get data and establish processes Your sustainability comes from gaining more of the premium dollar by saving payors money What are the risks? Transforming your delivery system is a lot of work. What will you stop doing that you do now, so you can spend time learning, redesigning workflows and reaching out to your patients? If your ACO closes before the third year, you have to pay back your grant funds so contract carefully to protect yourself. If you are really good at coordinating care, and you don t build market share at the same time with these programs, you could lose admissions, your payor mix could change and you could lose revenue you must regulate the pace of change and build market share at the same time. If your collaborators have losses, they will wipe out your savings and you will not get paid your bonus don t count on shared savings

16 Should You Join an Urban ACO? What is your strategic plan? Do you have a choice of tertiary providers? Is the urban ACO the best clinically integrated network for your patients? Will they focus on your needs and your success? How will they help you learn to improve? How will they help you build market share? Who gets to see your data? What data will they provide you? How will savings be distributed? What costs will be deducted from your shared savings? 31 What Does It Mean To Join a Rural ACO? You work hard to provide better care for your community. You work hard to improve your market share. You provide more support for your doctors. You own and govern your ACO. You create leverage with payers and your referral network. You control your destiny and rate of change. You get all claims data on your patients. You get waivers that help you succeed. Your get recognized as a high value provider. If you apply by July, CMS will fund your transformation

17 Discharge Rates Create Meaningful Change Chronic Obstructive Pulmonary Disease Discharge Rates (Per 1000 Beneficiaries) NRACO COPD All ACOs COPD NRACO Benchmark All ACOs Benchmark Q Q Q Q4 33 Build Market Share 13,800 13,600 13,400 13,200 13,000 12,800 12,600 12,400 12,200 12,000 11,800 11,600 Attributed Beneficiaries 2014-Q Q Q Q

18 What Are Your Next Steps? Enroll in a population health program that provides cost data and focuses you on achieving high scores on ambulatory quality measures so you don t get left further behind. Join PQRS Join an urban ACO Form a strategic ACO Join a State Rural ACO Join a Practice Transformation Network Whatever you do, do something and do it now! 18