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ACO Coalition Discusses the Future of Medicare Payments and the Benefits of Providing More Care


When The American Journal of Managed Care's ACO and Emerging Healthcare Delivery Coalition met for the most recent Web-based session, the speakers discussed the importance of accountable care organizations as CMS moves forward with new reimbursement schemes and managing high-risk patients through coordinated care.

When The American Journal of Managed Care’s ACO and Emerging Healthcare Delivery Coalition met for the most recent Web-based session, the speakers discussed the importance of accountable care organizations (ACOs) as CMS moves forward with new reimbursement schemes and managing high-risk patients through coordinated care.

During the session, participants learned the ins and outs of the sustainable growth rate (SGR) formula repeal and what it means for fee-for-service and alternative payment schemes in Medicare, and how to identify patients who will benefit the most from a little extra care.

The next Web-based session will take place September 24, 3:30-4:30 pm EST.

Future of Medicare Payments

The ACO model is the right model at the right time, and the repeal of the SGR has made being in an ACO even more timely and pertinent today, explained Travis Broome, MPH, MBA, healthcare policy lead at Aledade.

Medicare has set up a choice going forward: either staying in fee-for-service and having those payments be scaled based on value, or participating in an alternative payment model (APM), where providers still receive fee-for-service payments based on the model instead of simply just a percentage.

While today’s choice in Medicare is essentially between the value-based modifier and the Medicare Shared Savings Program, with some overlap, that will change in tomorrow’s Medicare world, according to Broome. Under the SGR repeal bill, tomorrow’s choice will be between the merit-based incentive model system (MIPS), which consolidates the value-based modifier, meaningful use, and the physician quality reporting system into one program beginning in 2019, and APMs, like an ACO. And there will be no overlap—those who choose an APM are exempt from MIPS.

There can be some wild swings in annual revenue under MIPS given that the fee-for-service payment can vary by up to 18%. Meanwhile, the APM has the incentive of receiving a lump sum of 5% of the FFS payment for the previous year just for joining an APM model.

“The way Congress set this up, it’s going to drive folks to alternative payment models very successfully,” Broome said.

Care Coordination

Sheila Fusé, CEO of Primary Partners, discussed care coordination and identifying those patients who can benefit from more care and management. In 2010, 10% of Medicare patients accounted for more than 70% of costs, and their job is to identify patients before they join that 10%, when they can still manage the costs and care.

“What we find is that as the patients get in front of the doctors, they know how to manage the clinical care ... and what we heard from a lot of physicians is it was the social aspect that created so many of the costs,” she explained.

In order to identify the right population to provide more care to, Primary Partners looked at emergency room (ER) utilization—patients who had 3 or more ER visits in the last 12 months—and used physician referrals, identified the barriers—such as behavioral health issues, transportation, finances, health literacy—and used social workers to identify how to help manage those barriers.

Once the patients are identified, they set up additional outreach calls to check in—some physicians provide their personal cell phone numbers—and schedule regular, monthly primary care visits. After bringing in the care coordination and focusing on high utilization patients, the Primary Partners ACO has consistently seen a decrease in ER visits and ER visits that led to admissions.

“This is just one example of how we’ve been able to lower overall utilization, improve patient outcomes and patient satisfaction that at the end generate shared savings but in a really positive way,” Fusé said. “So it’s not about providing less, it’s about providing more to the right population of patients.”

About the ACO Coalition

As ACOs and other emerging delivery and payment models evolve and move away from traditional fee-for-service system models toward cost-effective and value-based care, the need to understand how these models will evolve is critical to building long-term strategic solutions. The mission of the ACO Coalition is to bring together a diverse group of key stakeholders, including ACO providers and leaders, payers, IDNs, retail and specialty pharmacy, academia, national quality organizations, patient advocacy, employers and pharmaceutical manufacturers to work collaboratively to build value and improve the quality and overall outcomes of patient care. Coalition members share ideas and best practices through live meetings, Web-based interactive sessions and conference calls. Distinguishing features are the Coalition’s access to leading experts and its small workshops that allow creative problem-solving. To learn more, click here.



CONTACT: Nicole Beagin (609) 716-7777 x 131

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