Opportunities for Growth in the New Administration
"Opportunities are like sunrises. If you wait too long, you miss them." ―William Arthur Ward
With the new administration coming into power this month, there is a lot of conjecture over what might happen. Overall consensus is the one business segment that is the most stable is Medicare Advantage. Trump is a supporter of Medicare Advantage, and so are Republicans, although long-term there is an opportunity to change the financing of premiums. The Marketplace (Obamacare) and Medicaid are in “limbo” until we get a better idea of what and when there will be changes and how drastic they will be for these programs. So if you are looking for growth in revenue and/or enrollment, Medicare Advantage can provide a good opportunity. The other good news is that in the past several years, the Medicare Advantage market has been stable, based on the metrics available, with few changes in average premiums, plan offerings, and insurer participation.
If you are looking at the opportunity to grow or expand, there are many parameters to consider. Whether you are a Medicare Advantage plan considering expanding either your service area or products, Medicaid plans looking to add either Medi-Medi plans or Special Needs Plans, or an Accountable Care Organization or Integrated Health System looking to jump into Medicare Advantage, now is the time to explore this opportunity. Many of our clients are finding the most prudent way to expand and grow is a strong, solid strategy and an implementation plan that begins with a feasibility study.
A feasibility study looks at the market, and that analysis helps to build a strategy going forward for three to five years. This analysis looks at the competitive, financial, and demographic factors of a market(s) to see what is the most viable. This leads to a feasibility model based on detailed financial projections, and Gorman Health Group’s feasibility study process utilizes an onsite strategy exploration to walk through the entire process of entering Medicare Advantage or expanding current products and service areas with an emphasis on risks and rewards. The next step is the development of product/network/benefit design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
No matter what your situation, this opportunity could be your sunrise, so don’t wait and join us for our webinar on January 31, 2017 at 1:00 PM EST for an informative session on how to conduct a feasibility study and taking it to the next step. Register now >>
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MACRA Final Rule: CMS Announces Flexible Approach
No doubt sighs of relief could be heard from across the industry when the Centers for Medicare & Medicaid Services (CMS) announced its flexible approach to next year’s reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS took these flexibilities even further in its final rule released last Friday. Below I dive into some of the changes CMS made for the 2017 “transition year” and beyond.
- Relief for Small Providers – The final rule steps back even further from its requirements that providers billing more than $10,000 under Medicare are required to comply with reporting requirements. CMS finalized that Merit-Based Incentive Payment System (MIPS)-eligible clinicians who do not exceed $30,000 of billed Part B allowed charges or 100 Part B enrolled beneficiaries are excluded from MIPS. According to CMS, this is about one-third of Medicare clinicians but only represents about 5% of Part B spending.
- CMS also previously announced it will allow for virtual groups where up to ten clinicians could combine into one group, however, virtual groups will not be implemented during 2017
- “Pick Your Pace” – CMS also codifies its prior announcement that it will allow for a “pick your pace” approach for the first reporting year, 2017. The first year essentially now contains five options:
- Report a full 90-day or one-year period to maximize chances to qualify for a positive payment adjustment.
- Report for less than one year but more than 90 days: more than one quality measure, more than one improvement activity, or more than the required advancing care information performance category in order to avoid a negative adjustment and possibly receive a positive adjustment.
- Report one measure in the quality performance category, one activity in the improvement categories, or the required measures of the advancing care information performance category and avoid a negative adjustment.
- Participate through an Advanced Alternative Payment Model (APM) and qualify for a 5% bonus incentive payment in 2019.
- Don’t report anything for a hefty 4% negative adjustment.
- Basics of MIPS and Changes for 2017 – Eligible clinicians will see either a negative, neutral, or positive payment adjustment of up to 4% under the MIPS program. CMS will also pay out bonus payments for exceptional performers between 2019 and 2024 (beginning with the 2017 reporting year). The payments are based on four categories, and CMS made some significant changes from its proposal:
- Quality – Full participation requires reporting on six quality measures or one specialty-specific or sub-specialty-specific measure set, five required advancing care information measures, and engage in up to four improvement activities for the highest score. For 2017, full participation is met by submitting at least one out of the six quality measures. However, higher points may be awarded for higher performance in the measure.
- Improvement Activity – CMS reduced the number of activities from six to up to four medium-weighted or two high-weighted improvement activities. Attesting to at least one improvement activity will be sufficient in 2017.
- Advancing Care – CMS reduced the number of total required measures from 11 to five. Reporting on all five would earn 50%, and reporting on the optional measures would allow for a possible higher score. CMS will also award a bonus score for improvement activities that utilize Certified Electronic Health Record Technology (CEHRT) and for reporting to public health or clinical data registries.
- Performance Category – Although CMS will raise the weight of this category, it will be weighted at 0% for the 2017 reporting year.
- Advanced APMs – Clinicians who are eligible to participate through an Advanced APM are exempt from the above MIPS requirements. Additionally, the Advanced APM track is eligible for a 5% bonus payment. In order to qualify as an Advanced APM, CMS finalized that a provider must bear a risk of a potential downside of 8% of all Medicare reimbursements or 3% of the expected expenditures for which the provider is responsible under the APM. Notably, CMS retracted its proposals relating to marginal risk and medical loss ratio (MLR) for now.
- “MIPS APMs” – CMS noted the significant criticism that many APMs will not meet the requirements to participate in Advanced APMs in 2017. For example, participants of Track 1 Medicare Shared Savings Program (MSSP) are not eligible as an Advanced APM. CMS moved forward with their proposal that these “MIPS APMs” are subject to MIPS reporting requirements, however, they will be scored using an APM scoring standard in 2017. CMS did announce it is developing an MSSP Track 1+ Model under which Accountable Care Organizations (ACOs) participating in Track 1 and new ACO participants could take more limited downside risk than Tracks 2 and 3 and still be eligible as an Advanced APM. CMS also announced it plans to reopen applications for some current APMs, such as the Medicare All-Payer Model and the Comprehensive Care for Joint Replacement (CJR) Model.
While CMS took the job of responding to industry feedback and “simplifying” the jump into the Quality Payment Program (QPP) for 2017 while moving forward with the move to QPP to an art form, the gargantuan 2,400-page final regulation is a hint of what’s to come. Reinventing the Medicare payment wheel is no simple task and will undoubtedly come with a slew of interim proposed rules as well as fixes to encountered problems during the first transitional years. This payment overhaul is only going to get more complicated, and the time to roll up those sleeves and get to work is now.
Resources
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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MedPAC Meeting Highlights
The Medicare Payment Advisory Commission (MedPAC) held a public meeting last week and had a full plate of a variety of topics from Accountable Care Organizations (ACOs) to Medicare Part B drug payment issues.
Some takeaways:
- The Woes with ACOs: MedPAC found that in 2015, the Centers for Medicare & Medicaid Services (CMS) paid Medicare Shared Savings Program (MSSP) providers $625 million. This means that after paying out $429 to providers who generated enough for savings, the agency lost money. One commissioner recommended MedPAC look into organizations that generated savings for CMS in order to better gauge which factors make an ACO succeed. Though true that ACOs are slow to show the progress everyone is hoping for, it is important to note organizations that have been in the program longer are showing more success.
- Quality Measurement: MedPAC once again discussed the possibility of a premium support system to be implemented for Medicare. The conversation focused heavily on the commission’s alternative concept for measuring quality in Medicare as well as finding quality measures that can be used across Medicare Advantage (MA), ACOs, and Fee-for-Service (FFS). MedPAC is becoming increasingly concerned the current quality program relies on too many clinical process measures that do not strongly correlate with health outcomes. Under MedPAC’s proposal, Medicare would use a small set of population-based outcome measures and patient experience to compare quality of care under each of the three payment models in a local area. This was the first of many conversations MedPAC will have on this topic over the next year.
- Imminent Move toward Biosimilars: MedPAC seemed to offer much support in moving forward with the greater use of biosimilars under Part D. The use of biosimilars in Medicare would likely lead to drastic drug program savings, especially for chronic conditions such as diabetes. Solutions thrown around included extending the coverage gap discount to include biosimilars, something that is currently only applied to brand name drugs.
- Part B Drug Payment Policies: Given that Part B drug spending has grown at an average rate of more than 8 percent per year over the lastfive years, the commissioners ran through several proposals on how to address this growth and tackle Part B payments. Options considered included increasing price competition, consolidating billing codes, limiting average sales price (ASP) inflation, modifying the payment formula, improving data, and restructuring the competitive acquisition program (CAP). The discussion did not end with any recommendations other than to continue to work on this matter. Of course, we are all anxiously awaiting CMS’ response to the flood of comments to its Part B Drug Payment Proposal.
- Behavioral Health: It was also suggested MedPAC explore policy solutions to the weaknesses in behavioral health services under Medicare. The commission discussed exploring both weaknesses in inpatient facilities for serious mental health issues as well as care in ambulatory settings. Solutions thrown around included integrating primary care with behavioral health specialists and examining readmissions and emergency room data to determine what kind of readmission measures and penalties could be used to drive better inpatient performance.
Resources:
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Aligning With MACRA: Infrastructure And Initiatives That Yield Results
The Centers for Medicare & Medicaid Services (CMS) had almost 4,000 responses from providers and health plans regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With almost 1 million provider groups potentially impacted by the proposed rule, small groups and individual practitioners (primary care physicians (PCPs) and specialists) are being forced to think of their medical practices as a real business. Most of these providers do not have the robust infrastructure compared to their clinical counterparts that fall into the Alternative Payment Model (APM) buckets — Accountable Care Organizations (ACOs), Independent Practice Associations (IPAs), or Clinically Integrated Networks (CINs).
In order to align with the proposed legislation, demonstrate quality, report data, and position the medical practice for shared risk programs, the providers who fall into the Merit-Based Incentive Payment System (MIPS) bucket will need to make some critical decisions. That is if they actually want to realize a positive Return on Investment from participating in the program.
Keep in mind, the following will apply to PCPs and specialists alike:
- Revamp and deploy a data strategy that reconciles and reports patient-level data across multiple delivery systems and sources. Data integrity, quality, and accuracy will make or break a practice's success. It will get worse before it gets better, but everything can be fixed.
- Conduct a comprehensive chart review and risk adjustment program analysis, collecting the baseline health and condition statuses for your attributed patient panels and evaluating the coding patterns of your clinicians with diagnostic authority (Physician Assistants, Nurse Practitioners, Medical Doctors).
- Build and implement a Quality Oversight and Operations work plan that oversees the delivery of superior patient experience activities and aligns clinical practice models with imposed Clinical Quality Metrics.
- Bridge the communication with consulting specialists and network health systems and mid-level clinicians to coordinate care, make informed clinical decisions, and avoid redundancies in care that historically incur unnecessary medical expenses (which would carve into any anticipated financial benefits that were forecasted at the onset of any risk-based payment model).
The way I see it, if the proposed legislation moves forward, providers will have the following choices:
- Join an established APM, like an ACO or a CIN (if they'll have you)
- Jump in with both feet and make a HUGE investment in the infrastructure outlined above
- Find "MIPS friends," create consortiums, IPAs, and other qualified practice models that meet the CMS criteria
- Become an employed provider in a health system or academic medical center
- Transition to a concierge medical practice model and succeed
Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities to determine the best approach to achieve success. This is not a one-size fits all program, and Gorman Health Group can help find the most realistic, effective, and actionable approach for you and your organization.
Please contact me directly at dweinrieb@ghgadvisors.com or at 202.774.8016.
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What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients? Read more in another article recently published on the GHG Blog >>
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Teaming with Providers: Incentives to Achieve Results
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on their provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.
How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?
Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks?
Whether your providers are still fee-for-service (FFS) or at full percentage of premium risk, a few building blocks will ensure success:
- Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
- Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 Effective Implementation: If the Centers for Medicare & Medicaid Services (CMS) predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among their payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into documentation for chronic conditions and quality priorities, they've got to keep the cash flowing
- Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations. For example, the inclusion of an incentive program for achieving data accuracy, timeliness, and integrity is a critical element in your risk adjustment work plan. Offering incentives for providers to achieve and maintain 95% coding accuracy on all diagnoses, meaning 95% of the diagnoses submitted by the provider that can be substantiated in the medical record, subject to a random validation review, can often become a path to shifting providers to more risk-based contracting. However, if your provider data is not correct or complete, the plan or its vendor can spend more time trying to find a provider than validate results.
- Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous Measurement, Re-Evaluation and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
In summary, there is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path — collaboration between the plan and the providers. By breaking down the silos and barriers, being transparent in our actions, and reporting, we can build the trust needed to ensure we are not "checking the boxes" on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.
Resources
GHG's multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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New AHC Model Supports Better Care, Smarter Spending & Healthier People
The Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI) recently announced the Accountable Health Communities (AHC) Model, which will examine whether systematically identifying and attempting to address health-related social needs of Medicare and Medicaid beneficiaries through referral and community navigation services can impact healthcare costs, reduce inpatient and outpatient healthcare utilization, and improve healthcare quality and delivery.
As Accountable Care Organizations (ACOs), integrated delivery systems, and community-based organizations collaborate on how to best meet the medical and socio-economic needs of our most vulnerable populations, this new grant opportunity is a way to further solidify and strengthen provider partnerships. "The AHC Model will allow providers to leverage the clinical and technology infrastructure they have built and test solutions and interventions for the health-related but unmet social needs such as food insecurity and unstable housing," said Olga Bronnikova, Senior Legislative & Policy Advisor at Gorman Health Group (GHG).
"Since the time of Hippocrates, physicians have known their patients' physical health is highly dependent on factors in their physical, economic, and social environment," said Leslie Mullins, Senior Consultant at GHG. "The World Health Organization (WHO) has described these Social Determinants of Health (SDH) as the conditions in which people are born, grow, work, live, and age, and studies have shown SDH account for 15% to 40% of the variance in health between different groups. The AHC model will directly address how improving the SDH will affect beneficiaries' healthcare costs and improve health outcomes.
Information about the AHC Model is available at Accountable Health Communities Model web page.
Eligible Participants:
Eligible applicants are community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers. All states are eligible. Medicare Advantage (MA) and Program of All-inclusive Care for the Elderly (PACE) organizations are not eligible to serve as bridge organizations.
Model Details:
The model is a five-year test which will aim to address beneficiaries' social needs in the following core areas:
• Housing instability and quality,
• Food insecurity,
• Utility needs,
• Interpersonal violence, and
• Transportation needs beyond medical transportation.
The model includes three tracks which will attempt to test the following service delivery approaches:
Track 1 — Awareness: Increasing beneficiary awareness of available community services through information dissemination and referral.
Track 2 — Assistance: Providing community service navigation to assist high-risk beneficiaries with accessing community services to address the identified social needs impacting their total healthcare costs, inpatient and outpatient healthcare utilization, and health and quality of care.
Track 3 — Alignment: Encourage partner alignment to ensure community services are available and responsive to the needs of beneficiaries.
- The bridge organization is responsible for coordinating community efforts to: Identify and partner with clinical delivery sites and community service providers.
- Conduct systematic health-related social needs screenings
- Connect beneficiaries to community resources via referrals for identified unmet health-related social needs.
- Tracks 2 and 3: Assist beneficiaries with accessing community resources through community service navigation.
- Track 3: Partner with and align community service partners to optimize community capacity to address health-related social needs.
Bridge organizations are expected to partner with:
- At least one Medicaid state agency.
- Clinical delivery sites including at least one of the following: hospital, primary care provider or practice, provider of behavioral health services.
Community service providers who can address the health-related social needs identified through a screening.
Award Information:
Up to $1 million to each bridge organization in Track 1 — Awareness
Up to $2.57 million to each bridge organization in Track 2 — Assistance
Up to $4.51 million to each bridge organization in Track 3 — Alignment
CMS anticipates awards will be made in the fall of 2016. The model period is five years, from January 1, 2017, to December 31, 2021.
CMS will support and fund:
• 12 cooperative agreements for Track 1
• 12 cooperative agreements for Track 2
• 20 cooperative agreements for Track 3
Instructions and Deadlines
Applicants must submit a letter of intent (LOI) to http://innovationgov.force.com/ahc by February 8, 2016. If an LOI is not submitted, any subsequent application will be ineligible. Applications are due by 1:00 p.m. EST on March 31, 2016. Applicants may apply for up to two tracks, but successful applicants will only be selected for one.
At Gorman Health Group (GHG), we have successfully assisted providers in forming ACOs and developing strategies to address the clinical and socio-economic needs of vulnerable populations within our communities. We are prepared to assist you in your decision-making process for which of the various tracks of the grant application to apply, completion of the grant application, and implementation of your program. As noted above, time is of the essence. Let GHG help bring your innovative care ideas to fruition.
For more information, please contact me directly at emartin@ghgadvisors.com.
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GHG's multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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ACOs Should Run for the Exits and Into Medicare Advantage
CMS recently released results from the Medicare Pioneer Accountable Care Organization (ACO) Program and the Medicare Shared Savings Program (MSSP). Once again the results are a mixed bag: quality is up, but the ROI for most participants is a joke. The update should have the most sophisticated demo sites running for the exits and into Medicare Advantage — but they need to move fast with the holidays and a February filing deadline for 2017 looming.
Pioneer ACO Program
CMS initially selected 32 health systems to participate in the program. It's down to 19 today. For the year 2014, 622,000 beneficiaries participated. Findings:
- Pioneer ACOs generated total savings of $120 million in 2014, a 24% increase from 2013 ($96 million) and $88 million in Year 1 savings.
- Eleven health systems generated gross savings beyond the minimum goal and received performance payments totalling $82 million. That's a pittance for what's been invested to participate. Of the 11 companies, a few reported notable savings:
- Banner Health in Arizona generated roughly $18.7 million in savings
- Partners Healthcare in Massachusetts generated roughly $13.2 million in savings, with around 70,000 beneficiaries participating.
- Beth Israel in Massachusetts lowered costs by 3.7% and generated roughly $9.8 million in savings.
- OSF Healthcare System in Illinois lowered costs by 3.0%
- Michigan Pioneer ACO in Michigan lowered costs by 6.3%
- Monarch Healthcare in California lowered costs 4.0%
Three Pioneers incurred the nightmare scenario of a giveback payment to CMS in 2014, including Beacon Health in Maine ($2.9 million), Dartmouth-Hitchcock in New Hampshire ($3.6 million), and Franciscan Alliance in Indiana ($2.5 million). All had to inform CMS of their decision to stay or exit the program by September 14. After two years of consecutive losses, Dartmouth-Hitchcock planned to exit Pioneer and apply instead for the Next Generation ACO program. It's a black eye for the system that's home to Dr. Elliott Fisher, widely considered to be the inventor of ACOs. Beacon Health is also exiting the program after facing losses for two years in a row, and will also apply for Next Generation.
Total model savings per Pioneer was $6.0 million in Year 3 (2014), up from $4.2 million per ACO in 2013 and $2.7 million per ACO in Year 1 (2012). The mean quality score among Pioneer ACOs increased to 87.2% in 2014, an improvement of 200bps from 85.2% average performance in 2013, and way ahead of 71.8% in Year 1. The Pioneers improved on 28 out of 33 quality measures. So most are delivering the quality goods, but aren't seeing much if any return for the effort.
Medicare Shared Savings Program
In 2014, there were 333 participants in the Medicare Shared Savings Program, and 92 of these ACOs kept spending below their targets, up from 58 ACOs out of 114 in 2013. The victorious 1/3 earned $341 million in performance payments. Takeaways:
- $465 million of the savings generated will accrue to the Medicare Trust fund, $341 million will be returned to participants.
- 89 ACOs actually reduced health care costs compared to their benchmark, but did not qualify for shared savings because they did not meet the minimum savings threshold. So 2/3 of ACOs are winning on expense, but only half of those got paid. That's a problem.
- Veteran ACOs were more likely to generate performance payments. Twice as many ACOs that entered the program in 2012 got paid vs. freshman systems (38% vs. 19%).
Lined up alongside other innovation failures like the bundled payment and nursing home quality demonstrations, it's clear CMS's innovation agenda has been hobbled by poor design and lack of business acumen. There's never been a better time for an industry veteran like Andy Slavitt to lead the agency out of the darkness.
The clock is ticking for ACOs to make the evolutionary leap into the one "devil we know" of Medicare Advantage.
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Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Visit our website to learn more >>
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