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GE Healthcare Camden Group Insights Blog

Truth Be Told: What CMS Doesn’t Tell You About the Medicare Shared Savings Program

Posted by Matthew Smith on Sep 28, 2016 11:10:56 AM

By Andy McNerney, Manager, GE Healthcare Camden Group


When the Centers for Medicare & Medicaid Services ("CMS") launched its Medicare Shared Savings Program ("MSSP") in 2012, CMS leveraged the upside, risk only-design and the opportunity to be a care model redesign champion. It also intended to lead the market in value-based care delivery as a way to entice ACOs to join the program. Four years and 539 accepted MSSP ACOs later, CMS released its most recent set of performance results for the 80 percent of ACOs that have survived the program.

While savings of more than $429 million and overall quality improvement sounds like cause for celebration, the real story begins by acknowledging that program success doesn’t come easily and requires hard and transformative work…just ask the almost 70 percent (n=272) of MSSP participants who failed to achieve a shared savings distribution. Even for those participants that did achieve program savings, it is likely that the set-up and operating costs associated with the ACO program threatened bottom line financial success…today. But care transformation is not just about today’s bottom line, is it? Program veterans, or those who have participated for more than one Performance Year, have shown that it takes years to truly make an impact on cost and quality. The rest of the story will be written by their continued success as they gain a strategic advantage and encourage other providers to invest in their own transformation.

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If CMS Isn’t Telling the Whole Story, Define and Measure Your Own Success!

Participation in the MSSP is not only an opportunity to impact select quality metrics and recuperate some dollars lost as a result of reduced unnecessary utilization. It is a long-term strategic play to prepare for the not so distant future when up- and down-side risk taking will be the norm, not the exception. The data provided from CMS through the MSSP program is neither real-time nor risk-adjusted, making it extremely difficult for ACOs to assess their performance. In addition, the influx of participants makes it challenging to track and trend an ever-moving target. Furthermore, performance on quality measures is not released to the ACOs until Quarter 2 of the following performance year.

This leaves the ACO limited time to review performance, establish initiatives, and implement efforts to improve outcomes. ACOs need to develop a mechanism by which they can continuously monitor overall cost of care and performance on the established quality measures so that they are not relying on CMS to report on their progress. Instead, continuous process improvement and measurement needs to be the new normal in preparation for a time when CMS will not be the only value-based contract in place. The amount of shared savings achieved, the level of patient satisfaction, and the quality outcomes delivered at the end of each Performance Year should not be a surprise, but all too often it is!

The Focus On Quality Should Go Beyond MSSP Attributed Lives!

The overall quality improvement shown by the MSSP ACOs indicates a program-wide commitment to improved health outcomes that should be applauded. These measures focus on patient satisfaction, reduction in avoidable utilization, preventive care, and evidence-based protocols for at-risk populations. Successful performance on many of these measures requires substantial data aggregation and analysis and proactive outreach to MSSP ACO patients. Where many ACOs falter is by laser-focusing on only the MSSP population; those beneficiaries assigned to the MSSP receive proactive preventative care while other patients are overlooked.  While this can be a successful short-term strategy (particularly when resources are limited or information systems have not yet have matured), operationalizing it is a challenge and this approach will not position the organization for long-term success.

Quality outcomes initiatives should be inclusive of all patients, regardless of payer, to demonstrate that your model of care can be scaled and to attract similar shared savings arrangements beyond CMS. The bigger problem is that care delivery does not just change for a given population and organizations are realizing that other payers are benefiting from their performance improvement efforts, which causes barriers to engage these providers in value-based contracting because the organization is producing results that are benefiting the payer without the compensation.

In 2015, CMS set a goal of having 50 percent of Medicare payments made through alternative payment models by 2018. Providers have responded through strong participation in programs such as MSSP, Pioneer ACO, and Bundled Payments and indications are that value-based payments will become the standard. If your organization embraces a value-based world, then program participation can be a good step towards building the necessary muscle. But only if you make a full organization wide commitment to the cultural change required to support care model redesign and do so with a customized definition of success; because unsuccessful participation may be even more costly to an organization than no participation at all.

Organizations who don’t take the time to invest in the appropriate care coordination resources will find that they have spent money on ACO staff, slightly reduced inpatient utilization (and therefore revenue), and receive no shared savings distribution to offset these costs. This can be a very frustrating result, leading to dissatisfaction with the program and disillusionment with care coordination. So, jump in! But don’t leave the necessary people, data, or innovation behind. 


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Mr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com

 

 

 

Topics: MSSP, CMS, MSSP ACO, Andy McNerney

National Association of ACOs: MSSP Commitment Hinges on MACRA Advanced APM Bonus Eligibility

Posted by Matthew Smith on Jun 6, 2016 1:14:09 PM
According to a May 2016 survey by the National Association of ACOs ("NAACOS"), more than half—56 percent—of accountable care organizations ("ACOs") in the Medicare Shared Savings Program ("MSSP") indicated they would leave the MSSP program if their ACOs were not eligible for the 5 percent Advanced Alternative Payment Model ("APM") bonus under the Medicare Access and CHIP Reauthorization Act ("MACRA").

A third of the ACOs said they would stay in the MSSP program even if deemed ineligible for the bonus, the NAACOS survey found.

The Alternative Payment Model ("APM") is one of two paths for participation in the quality improvement programs included in the MACRA legislation for eligible professionals; the other is the Merit-Based Incentive Payment System ("MIPS").

Currently, MSSP Track 1, a one-sided payment model, is not among the models that would qualify for the APM track—which CMS calls "Advanced APMs"—under the proposed MACRA rule; however, the MSSP Tracks 2 and 3, Next Generation, and Pioneer ACO programs, which all require downside risk, would qualify as APMs.

Approximately 411 MSSP ACOs, or 95 percent, participate in Track 1 of the program, according to April 2016 data from CMS.

All APM qualifying participants will receive a 5 percent lump sum bonus on their Medicare payments for 2019 through 2024. This bonus will be in addition to the incentive paid through existing contracts with the qualified APM (e.g., MSSP) demonstration program, etc.

Beginning in 2026, these ACOs will qualify for a 0.75 percent increase in their payments each year.

In other findings, the NAACOS survey also determined the following:

  • More than half of respondents (51 percent) describe their ongoing ACO operational costs as very significant;
  • The average total ACO operating costs for all respondents is $1.6 million per year, but the cost difference is significant between single or multi-ACOs, with single ACOs averaging just under $2 million and multi-ACOs averaging almost $1 million per year.
  • If required by CMS to take on downside risk, 43 percent said they would leave the MSSP program and about a third would stay (33 percent).
  • Over three quarters of the ACO respondents (84 percent) said they would be ready for downside risk within the next six years, with 44 percent of those even ready as soon as one to three years.

A PDF version of the full report may be downloaded here

MACRA

Topics: ACO, MSSP, Accountable Care Organizations, MACRA, MIPS

MSSP and NGACO Application Windows Quickly Approaching

Posted by Matthew Smith on Apr 6, 2016 11:50:17 AM

CMS recently launched the first step of the application process for its Next Generation ACO (“NGACO”) Model, and next month opens the window to apply for the Medicare Shared Saving Program (“MSSP”) Initiative. The NGACO, CMS’ newest two-sided risk model, accepted 21 organizations for 2016. The MSSP, which also added enhanced risk-based options in 2016, had 100 new ACO participants this year, bringing the total to 434 ACOs at the start of the year. These numbers reinforce CMS’ stated goal to move 30 percent of traditional Medicare fee-for-service payments into alternative value-based payment models by 2016, and 50 percent by 2018.

MSSP: Zero Downside Risk

The MSSP Model was introduced in 2012 as a key component of the Medicare delivery system reform initiatives found in the Affordable Care Act and a new approach in the delivery of health care intended to facilitate coordination among providers to improve the quality of care. Among the primary attractions of the MSSP was the option to participate with zero downside risk, meaning if organizations outspent their target expenditures, they would not be liable to repay the difference to CMS. Through Track 1 there existed only upside, or the ability to share in any savings generated, an appeal that the MSSP Model maintains to this day. This allows organizations to dip their toes in the accountable, value-based waters and develop the infrastructure necessary for future success while still participating in a fee-for-service environment today. And the participating organizations have largely voiced their approval of the program – more than two-thirds renewed their participation when their initial agreement ended in December.

NGACO: Higher Risk/Higher Rewards

While the MSSP Model was the right first step for many organizations beginning their journey towards value-based care, it was in many ways insufficient for more advanced organizations experienced in care management and risk-based contracting. Thus the Next Generation ACO model was born, providing a higher-risk, higher-reward alternative to the MSSP, while simultaneously responding to and improving upon its oft-maligned and challenged predecessor, the Pioneer Model, with a refined attribution process and enhanced benchmarking methodologies. Now organizations can select between two risk options from 80 to 85 percent on the shared savings option all the way to a full-risk opportunity. Now if organizations overspend their benchmark expenditures, they will have to cut CMS a check at the end of the year. This may seem daunting, but many organizations view this as the natural programmatic evolution and that the increased skin in the game can be the push their organization might need to really enact the necessary transformation. In fact, seven of the new NGACO participants came from the MSSP program, demonstrating the interest of existing program participants to advance their risk exposure and opportunity based on their work and success to date.

The NGACO, with its enhanced risk profile, is obviously not for everyone, which explains why only 21 were accepted in the past cycle. As stated above, the NGACO was effectively developed for those organizations with experience in commercial ACOs or with value-based contracts, or that had experienced success in the MSSP and had outgrown the less-lucrative risk arrangement. Accordingly, in addition to the seven MSSP converts to the NGACO program, eight made the transition from the similarly two-sided, but less favorable Pioneer model.

Deadlines Approaching

The good news for organizations wanting to prepare for a value-based future is that the 2017 application windows for both programs are upon us. Organizations contemplating their fit in either initiative can apply for one or both, but need to submit their Notice/Letter of Intent by the respective deadlines to be considered. These submissions are non-binding, so we encourage organizations at all considering participation to file one and then assess their options in the next few months. One caveat is that while organizations can simultaneously apply for both models, they will ultimately only be able to participate in one of the two initiatives.

The NGACO Letter-of-Intent is due May 2, with the MSSP Notice-of-Intent due May 31. Additional key milestones for both models can be found below:

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With the continuous innovations of both payment and delivery models, CMS is maintaining its commitment to the transformative shift to value-based care. While that momentum is undeniable, not all organizations are necessarily ready for that transition just yet, particularly in the riskier models. We recommend undergoing a comprehensive (and candid) self and market assessment of your organization’s present situation and evolution in what GEHC Camden Group considers the eight core domains essential for clinical transformation to successfully thrive in a value-based world. A commitment must be demonstrated in the below key operational competencies in order to achieve success in the changing landscape.

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CMS has reiterated its commitment to population health with its ongoing development and support of these accountable initiatives. Even more encouraging, CMS has demonstrated a willingness to adapt and improve to encourage participation and collaboration. The strongest healthcare organizations tend to be the ones that are proactive rather than reactive. For organizations that can see what’s coming down the tracks, there may be no better time than now to begin preparing for a value-based future.

Next Generation ACO

Topics: ACO, MSSP, Population Health, CMS, Next Generation ACO Model, MSSP ACO, NGACO

The Medicare Shared Savings Program Final Rule: What You Need to Know

Posted by Matthew Smith on Jun 8, 2015 1:59:00 PM

By Tawnya Bosko, MHA, MSHL, MS, Senior Manager, The Camden Group

mssp_news.pngOn December 1, 2014, the Centers for Medicare and Medicaid Services (“CMS”) published proposed changes to the Medicare Shared Savings Program (“MSSP”) regulations, with the final rule being announced on June 4, 2015. While the timing of the release of the final rule isn’t optimal for those that may have considered participating in the upcoming round of entrants, the final rule further clarifies CMS’ intent to facilitate the movement to value-based payment methodologies. Many of the changes were adopted as proposed, while some others were altered from the proposed changes. Here are highlights of some key changes in the final rule and what it means to accountable care organizations (“ACOs”).

Extending the Time Period for Participation in Track 1

Previously, Track 1 ACOs (no downside risk) were limited to one three-year agreement period before converting to a risk-based track. The final rule allows participants to remain in Track 1 for an additional 3-year performance period, or a maximum of two three year periods without the reduced sharing rate that CMS had proposed. This proposal allows those ACOs who have seen modest improvements in their ACO operations and performance and/or those who are not ready for performance-based risk a little more time to implement and execute.

Assignment of Beneficiaries

The assignment of beneficiaries was historically a two-step process based on provision of primary care services by 1) Primary Care Physicians and 2) Specialists and Advanced Care Practitioners (“ACPs”) (e.g., nurse practitioners, physician assistants and clinical nurse specialists). The final rule revises the process to include ACPs in Step 1 and removes specialties which are unlikely to provide primary care services. This proposal effectively moves the beneficiary assignment toward the provision of primary care and allows the specialists who want to participate in multiple ACOs the flexibility to do so. Further, through rulemaking in the 2017 Physician Fee Schedule, CMS expects to propose that beneficiaries may attest that their main doctor is participating in a performance-based risk track ACO and be assigned to that ACO. Assignment methodology and fluctuations have been a pain point for many ACOs.  While this may not be a cure, it does work to address many of the concerns.

Sharing of Data

CMS previously shared certain claims data with ACOs only after ACOs had 1) notified their beneficiaries of that data sharing via direct mail or at the time of service and 2) provided them an opportunity to opt out of data sharing. This time-consuming process was onerous for the ACO and its providers and delayed the receipt and review of data which is key to the success of the ACO. It was also confusing for beneficiaries who received letters in the mail and at the point of care. The final rule allows ACO providers to post signs in their facilities with template notification language that will notify beneficiaries of their right to opt out by calling CMS directly. The proposal removes the ACO from the data sharing consent process – a win for current ACOs who have found the beneficiary notification process to be exceedingly burdensome and a distraction from the primary work of population health management.

Revisiting the Methodology for Establishing, Updating, and Resetting the Financial Benchmark

The current methodology based on the ACO’s past performance that CMS uses for setting, updating, and resetting the ACO’s financial benchmark is flawed. It gives increased opportunity to those ACOs with high utilization and costs and inadvertently penalizes those that have already moved to improve quality and manage costs. Additionally, the method gives diminishing returns over time as ACOs succeed in achieving savings year over year. Once the cost curve has reset, there will be little to no savings left to share. CMS sought comment on alternative ways of benchmarking ACOs for shared savings, including options of comparing ACO providers to the spending patterns of non-ACO providers within their region. In the final rule, CMS formalized the process to equally weight the historical benchmark years, as opposed to weighting those years 10% for benchmark year (“BY”) 1, 30 percent for BY2, and 60 percent for BY3 at the start of the second or subsequent agreement period; and indicated intent to commence rulemaking later this year to implement a methodology that would reset ACO benchmarks in part based on trends in regional fee-for-service costs rather than solely on an ACOs’ own recent spending. The consideration of a revised method that can better reflect the underlying health of the population to reset the benchmark is encouraging. A more precise and accurate reflection of the health of the assigned population will further improve patient experience and enhance the value of the care provided while achieving savings for CMS.

Incentivizing ACOs to Move Toward Risk-Based Models

CMS has finalized the creation of a new Track 3, a performance risk-based model, which will have a higher sharing rate than Tracks 1 or 2 at 75 percent of all savings or losses and would offer prospective assignment of beneficiaries rather than preliminary assignment with retrospective reconciliation. Additionally, CMS modified Track 2 to allow ACOs to choose from a selection of options for setting their minimum savings rate (“MSR”) and minimum loss rate (“MLR”) in an equilateral manner, with either no MSR/MLR, equilateral MSR/MLR in .5 percent intervals between .5 and 2 percent or equilateral MSR/MLR to vary based on the number of assigned beneficiaries as in Track 1. In the final rule, the new Track 3 will follow the same methodology as Track 2.

CMS also indicated its intent to further test the billing and payment requirements for telehealth services via its newly created Next Generation ACO model. It is anticipated that a telehealth waiver may be available to ACOs in the Track 3 model by January 1, 2017.

Additional refinements include minor changes to the eligibility for participation in the MSSP, including removal of the requirement that the ACO’s medical director be an ACO provider/supplier; and a more streamlined process for Pioneer ACOs to apply for program participation, among others.

While it remains to be seen if the proposed changes will encourage more provider organizations to join the MSSP, it is clear that CMS is creating various models to fit the needs of different types of organizations. Determining which model is appropriate considering the unique characteristics of your organization will be key to success.

Table. 1. MSSP Final Rule Changes and Characteristics of MSSP Tracks 1-3

(Note: Click here for a PDF download of the table or here for an image file.)

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Source: The Centers for Medicare and Medicaid Services, 2015


bosko_headshot.pngMs. Bosko is a senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization  and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.

 

 

 

 

Topics: ACO, MSSP, Medicare Shared Savings Program, Accountable Care Organizations, Tawnya Bosko, MSSP ACO, MSSP Final Rule

Pioneer ACOs: Pass or Fail, the Model is Here to Stay

Posted by Matthew Smith on May 14, 2015 1:13:38 PM

By Daniel Juberg, Senior Consultant, The Camden Group

aco_logo-gold.pngLove them or hate them, it’s that time of year when America is getting inundated with high-profile, big budget sequels. The Centers for Medicare and Medicaid Services (“CMS”) is getting in on the act with a follow-up and expansion to the controversial Medicare Pioneer Accountable Care Organization ("ACO") program that was launched in 2012. Following the recently released positive results for the program from 2012 to 2013, CMS is declaring the program a success. But then, why did over 40 percent of the Pioneer ACOs drop out of the program in the first place? And just how should healthcare providers react to this expansion news?

Launched in 2012, the Pioneer ACO Model was designed for healthcare organizations and providers who were already experienced in coordinating care for patients across care settings. Through the alignment of provider incentives to improve quality and health outcomes for patients across the ACO, the program aimed to transition more rapidly from a shared savings payment model to a population-based payment model. The Pioneer Model operated on a track that was consistent with the more popular Medicare Shared Savings Program ("MSSP"), but with greater downside risk and greater levels of shared savings for successful performance.

CMS only allowed organizations to participate that it believed to be the most experienced in care coordination and with the highest chance of success. This led to only 32 brave, inaugural ACOs, or “Pioneers,” as CMS’ first batch of participants. Since 2012, 13 of the 32 Pioneer ACOs have left the program, either exiting Medicare accountable care models completely or transitioning to the less lucrative but also “zero risk” MSSP (Track 1). The majority of ACOs who exited the Pioneer program reportedly found it too costly, too risky, or just simply too complex.

Nearly $400 Million in Pioneer ACO Savings 

However CMS recently announced that, in total, the 32 Pioneer ACOs combined for $384 million in savings over the two-year period, an average of $300 in savings per beneficiary annually. This reduction was achieved largely through a population exhibiting lower hospital utilization, incurring fewer tests and procedures, and undergoing more provider follow-ups after being discharged from a hospital. These positive results have expedited CMS’ stamp of approval for expansion to a larger population of beneficiaries.

What remains unclear is exactly how these ACOs achieved the results and how to establish a more sustainable model (the ACOs saved substantially more in 2012 than in 2013 - $280 million vs. $105 million). But what is clear is CMS’ intent with their latest exuberant declaration: ACOs and population-based payment models are here to stay.

The first wave of CMS’ commitment to promoting the shift in payment methodologies was with the proposed new Track 3 through its MSSP. CMS is currently inserting the design elements from the Pioneer ACO model into the proposed Track 3. Traditionally ACOs participating in the MSSP had two risk arrangement options: Track 1, which presented no downside risk but a lower shared savings rate; and Track 2, which offered a greater shared savings rate but came with the burden of shared losses as well. The proposed Track 3 offers a higher maximum shared savings rate in exchange for accepting greater downside risk. Track 3 proposes a shared savings rate up to 75 percent based on quality, 15 percent higher than in Track 2. However, under Track 3, the ACO’s proposed shared loss rate ranges from 40 to 75 percent based on quality.

Next Generation ACO Model

CMS also recently unveiled the Next Generation ACO model, which offers financial arrangements with higher levels of risk and reward than current Medicare initiatives. This model is an attempt to correct perceived shortcomings of the original Pioneer model with refined benchmarking methodology and improved benefit enhancement tools to help ACOs improve engagement with beneficiaries. With offerings including a selection of payment mechanisms to enable a graduation from fee-for-service reimbursements to capitation, the Next Generation ACO model is similarly targeted at seasoned care management organizations. Again, the message from CMS regarding Track 3 and the Next Generation ACO is clear – only the most experienced in care coordination need apply.

CMS is in the process of evaluating further expansion options based on the positive Pioneer results. So what can healthcare providers, hospitals, and health systems take away from these performance results and announcements in the meantime? By now it is unmistakable that CMS is committed to the shift towards population-based models using the current shared savings arrangements as a conduit. Healthcare providers and organizations need to develop a strategy on where and how they enter into the path to value-based payments. The question no longer is if, but when.

Not for the Faint of Heart

Only the most experienced organizations are prepared to try their hand at the lucrative (yet aggressive) Track 3 or the Next Generation ACO; as we saw with the early Pioneer entries, many of those will fail. But there are plenty of other entry points for organizations to dip their toes into the accountable care and value-based payment waters. The most closely aligned initiative of course is through Track 1 of the MSSP, which offers no downside risk to participants through the first three years of the program. Track 1 allows organizations to build the infrastructure necessary to coordinate care and manage a population with little financial risk. Organizations can simultaneously recruit, refine, and strengthen their clinically integrated networks without being on the hook to CMS financially should they endure growing pains and overspend their benchmark expenditure for the year.

CMS has set a target for 50 percent of Medicare payments to be shared savings or population health payment models by 2018. Organizations need to ask themselves if they are putting themselves in the optimal position to survive and thrive as the landscape shifts to these alternative payment models.

Will you have the infrastructure, care management protocols, and network to support the transformative shift to value-based care? Evaluate your market. Are there opportunities to collaborate? What are your competitors doing? Are payers approaching your market with value-based contracts? Now is the time to discuss and strategize how your organization will adapt to the evolving payer environment and whether participating in one of CMS’ Shared Savings Programs can act as the impetus for change to propel your organization to future success.

CMS has made it clear that ACOs and alternative payment models are here to stay. What’s becoming unclear is whether organizations that don’t successfully prepare themselves for that reality will be as well.


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Mr. Juberg is a senior consultant with The Camden Group and focuses on clinical integration, transactions, and strategic and business planning for healthcare organizations. He has extensive experience with the development of ACOs (financial planning and funds flow modeling), managing Medicare Shared Savings Program applications, and implementing clinically integrated networks. He is also experienced in master facility planning, CMMI Innovation Center grants, medical group valuations, and community needs projections. He may be reached at djuberg@thecamdengroup.com or 310-320-3990.

Topics: MSSP, Accountable Care Organization, CMS, Pioneer Accountable Care Organization, Next Generation ACO Model, Daniel Juberg

Remind Me Again...What's the Difference Between an ACO and a PCMH?

Posted by Matthew Smith on May 8, 2015 9:54:28 AM

pcmh_new.jpgThe Patient-Centered Medical Home ("PCMH") model was proposed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association in 2007.

It is, in essence, an enhanced primary care delivery model that strives to achieve better access, coordination of care, prevention, quality, and safety within the primary care practice, and to create a strong partnership between the patient and primary care physician. Like accountable care organizations ("ACOs"), the medical home model is referenced many times in the current Affordable Care Act as one way to improve health outcomes through care coordination.

Medical homes are similar to ACOs in that they consolidate multiple levels of care for patients. However, medical homes take the approach of having the primary physician lead the care delivery “team.” Quite simply, an ACO consists of many coordinated practices while a medical home is a single practice. 

A medical home has several key characteristics, including:

  • Designation of a personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.  Also, the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
  • Whole person orientation – care is organized around providing services for all of the individual’s health care needs.  The medical home takes responsibility for appropriately arranging care with other qualified professionals on an as needed basis.
  • Care coordination and integration – care across the spectrum of specialists, hospitals, home health agencies, and nursing homes is coordinated with the personal physician leading the effort.
  • Evidence and outcomes focus – the quality and safety of care are assured by a care planning process using evidence-based medicine, clinical decision-support tools, performance measurement and active participation of patients in decision-making.
  • Enhanced access to care – practices are “open” in the sense that scheduling is available to individuals, hours of practice are expanded hours and new communications options are deployed for the convenience of individuals seeking care.
  • Comprehensive payment model – payments for services for individuals enrolled in the patient-centered medical home reflect a comprehensive payment for services that extends beyond the face-to-face visit with the personal physician.

The ACO is also based around a strong primary care core. But ACOs are comprised of many "medical homes"—in other words, many primary care providers and/or practices that work together. Some have even dubbed ACOs the "medical village."

An ACO is basically a network of medical homes. It is a collaboration of different organizations and practices working together which may include primary care physicians, specialists, hospitals, providers, payers, etc. The ACOs take medical homes a step further in emphasizing the alignment of incentives and accountability for providers across the continuum of care. There is a need for very strong leadership to address cultural, legal, and resource related barriers when creating an ACO.

The difference is that ACOs would be accountable for the cost and quality of care both within and outside of the primary care relationship. As such, ACOs must include specialists and hospitals in order to be able to control costs and improve health outcomes across the entire care continuum.

ACOs by nature would be larger than a single medical home or physician’s office. There are many known benefits of the ACO structure over the medical home model, including the ability to better manage the care for a greater population of people with a larger budget. Being able to use the dollars across a wider range of patients and conditions allows for better overall cost management, less variation within the population, and the ability to track and trend for quality.

MSSP Overview, Medicare Shared Savings Program

 

 

 

 

Topics: ACO, MSSP, PCMH, Patient Centered Medical Home, MSSP ACO

Are You Considering the Medicare Shared Savings Program?

Posted by Matthew Smith on Apr 22, 2015 2:41:00 PM

By Daniel Juberg, Senior Consultant, The Camden Group

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With the recent Centers for Medicare and Medicaid Services (“CMS”) announcement of the 2016 Medicare Shared Savings Program (“MSSP”) application cycle, many provider executives find themselves evaluating if the time is right for their organization to apply. CMS allows organizations only one opportunity per year to apply. The May 29, 2015 deadline to submit a non-binding Notice of Intent to Apply is rapidly approaching. Can your organization wait until 2017? Here are some considerations for why the Medicare Shared Savings Program could be the right move for your organization now.

Control Your Competitive Landscape

Take a moment to evaluate your competitors. Who are your competitors and what are they doing? This includes traditional competitors, like hospitals, health systems, and physician groups, as well as other non-conventional competitors who provide ancillary healthcare services, such as pharmacies and retail clinics. Are they forming accountable care organizations (“ACOs”) or similar, value-based organizations? Are they considering or even already participating in the MSSP? If so, their participation could preclude or delay the success of yours in the future. Many executives are using the MSSP as a defensive maneuver to build or protect market share. How? ACOs must have a minimum patient assignment of 5,000 Medicare lives to be eligible to participate in the MSSP. These lives are attributed, predominantly through participating primary care physicians, to the ACO through the group/physician Tax Identification Numbers (“TINs”) that sign participant agreements with them. These TINs can only participate in one ACO in the MSSP. This assignment exclusivity is a defined population play for your organization. Through the MSSP, you can build and/or solidify your primary care base and the patients for whom they care. Even if your competitors are not in the MSSP, this is the opportunity to lead your market, align your physician partners, and solidify your position in the Medicare landscape.

Consider the current payer activity in your market. Are payers currently approaching you or your competitors with value-based, shared savings contracts? Have you considered the infrastructure and care coordination redesign that such arrangements might require? Commercial and government payers are already moving towards value-based payment, so the urgency to transform care delivery models for success in value-based payment models is real. The MSSP can be used as the impetus for change, help you stay ahead of the game, and prepare you for future success under value-based payment.

Prepare for the Triple AimTM

Consider the opportunity to coordinate care and improve quality - with little financial risk. The MSSP allows you to build the infrastructure framework – a coordinated care network that spans the continuum – for the ACO without downside financial risk for the first three years. It provides a simple platform to develop a mutually beneficial, ever-evolving financial funds flow to encourage and support clinical behavior change along the care spectrum. Through the physician-led organizational structure, clinicians are engaged in care model redesign that maintains the patient at the center of their care. Organizational leadership and participants work together to develop quality, patient satisfaction, and performance metrics for transparent reporting and subsequent measurement, which encourages EMR use and physician connectivity and participation. Through this dedication to value-based and coordinated care, all participants are contributing to the achievement of better quality, cost savings, and healthy patients – which will be rewarded with upside incentives in MSSP and commercial ACO initiatives. Gaining this experience with little risk will enable the organization to begin the “rewiring” process to allow participation in other higher risk (and reward) models that may be offered by payers in the future.

Evaluate synergies to better manage care for other target populations. Organizations can also use shared resources developed for the MSSP to incorporate their employee population within the ACO infrastructure to pilot the care coordination efforts and a similar shared savings program. Additionally, some are finding system-wide, cross- payer synergies that benefit their bottom line and keep patients in their care network. For example, some organizations are using their Call Centers or “Hotlines” to not only answer questions about the ACO as required by CMS, but to provide 24/7 physician access, encouraging patients to seek care within their network or sphere of influence while reducing unnecessary emergency department admissions through the use of an urgent care facility.

Evaluate Potential for Profitability Under MSSP

Assess the impact on revenue against your ability to manage costs and achieve efficiencies. ACOs in the MSSP are absolved from downside financial risk for the first three years of the Track 1 program as they work to recruit, refine, and strengthen their clinically integrated networks. But, can you be “profitable” under MSSP? Possibly. In a fee-for-service environment, savings can be generated as a result of the ACO’s cross-continuum care delivery model which streamlines workflow and transitions of care to reduce waste and inefficiencies. This often begins with the reduction of costly acute care hospital-based utilization. Consider, particularly if you are a hospital, how much you can reduce inpatient utilization under the MSSP and whether you can offset the loss of inpatient opportunity with additional patient throughput and capacity across the system. Also, will you be able to grow market share and align MSSP participation with ongoing expense reduction and operational improvement efforts, such as through Lean and Six Sigma? For those with experience in medical management and managed care, you may be particularly well positioned for MSSP. Further, as the federal budget gets squeezed, obtaining any upside in Medicare payment will be important as traditional fee-for- service payments get cut.

Success in the MSSP relies on the ability of an organization to appropriately manage the care, utilization, and cost of a defined population while continually improving quality and clinical outcomes. It also requires full commitment and a clearly defined vision; half-hearted efforts will fail and can be costly both organizationally and financially. Participating in the MSSP will test, facilitate, and/or impel your organization’s path to value-based care. Dipping your toes in the MSSP water may not be the risky proposition - the real risk might lie in not acting now.

MSSP Overview, Medicare Shared Savings Program


jubergMr. Juberg is a senior consultant with The Camden Group and focuses on clinical integration and ACOs (financial planning and funds flow modeling), Medicare Shared Savings Program applications, and strategic planning. He is also experienced in service line assessment and planning, bundled payments, CMS Innovation Center grants, medical staff needs assessments and development plans, as well as bed needs projections. He may be reached at djuberg@thecamdengroup.com or 310-320-3990.

Topics: ACO, MSSP, Medicare Shared Savings Program, MSSP ACO, Daniel Juberg

Reminder: Upcoming Next Generation ACO and MSSP ACO Webinars

Posted by Matthew Smith on Apr 16, 2015 5:09:57 PM

webinar_Clouds_icon-resized-600As a reminder, The Camden Group's Next Generation ACO webinar will be held tomorrow, April 17 at 12:00 p.m. ET. If you have not registered for this event and wish to do so, please register via the green button contained in the blog post. Registration remains open for next week's MSSP ACO webinar as well. Please click the "Read More" link, below, to access the full blog post.

The implementation of the new Next Generation Accountable Care Organization (“NGACO”) model for Medicare has made it increasingly clear that ACOs will be a significant part of the government’s commitment to tie 30 percent of traditional Medicare payments to quality or value through alternative payment models by the end of 2016, and 50 percent of payments to these models by the end of 2018.

Whether your organization is just beginning to think about taking steps toward accountable care and considering the Medicare Shared Savings Program (“MSSP”); or if your organization has advanced to the point of considering the NGACO model, The Camden Group’s complimentary webinar series will provide you with background information on the programs to help you make an educated decision as to whether to participate, when to participate and which program is right for your organization.

Join us on Friday, April 17 at 12:00 p.m. ET for the first webinar in the series focusing on the NGACO program. We will discuss the specifics of this new model and the skills needed for a successful launch. Topics will include:

  • An overview of the NGACO model and the key differences between other CMS programs
  • Types of prior experience will be important for success in the NGACO
  • The included alternative payment mechanisms, and unique opportunities for network alignment
  • Next steps and logistics to consider before applying

To register for the NGACO webinar, please click the button below:

NGACO Webinar, Webinar, The Camden Group, Next Generation ACO, Accountable Care Organization

Our MSSP program will be held on Thursday, April 23 at 12:00 p.m. ET. Based on our previous application cycle and operational experience, we will discuss the specifics of the MSSP model and important items for consideration in determining if the time is right for your organization to apply. Topics will include:

  • An overview of the MSSP model and the key differences from other CMS programs
  • The changing value-based landscape and where the MSSP model fits
  • Considerations for leaders evaluating the MSSP program opportunity
  • Key elements and logistics to contemplate before applying*

*The Notice of Intent to apply is non-binding and does not commit an organization to applying. 

To register for the MSSP webinar, please click the button below:

MSSP Webinar, Webinar, The Camden Group, Accountable Care Organization

 

 

 

Our expert facilitators for the webinars include:

bosko_backgroundTawnya Bosko | Ms. Bosko is a senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment.

 

 

glaserMishka Glaser | Ms. Glaser is a manager with The Camden Group, specializing in clinical integration, accountable care, and many other innovation strategies. She brings over 15 years of experience in various sectors of healthcare including physician practices, insurance, and pharmaceuticals. Ms. Glaser’s in-depth knowledge of value-based care operations provides a context for assisting clients in navigating population health.

 

jubergDaniel Juberg | Mr. Juberg is a senior consultant with The Camden Group and focuses on clinical integration and ACOs (financial planning and funds flow modeling), Medicare Shared Savings Program applications, and strategic planning. He is also experienced in service line assessment and planning, bundled payments, CMS Innovation Center grants, medical staff needs assessments and development plans, as well as bed needs projections.

 

keberWren Keber Mr. Keber is a manager with The Camden Group and specializes in the development, implementation, and operations of clinically integrated networks (“CINs”) and accountable care organizations. He has assisted hospitals and physician organizations nationwide in achieving clinical integration and success in value-based programs. He has particular expertise in the Medicare Shared Savings Program offered by the Centers for Medicare and Medicaid Service and has advised CINs in their preparation for and participation in the program.

Topics: Accountable Care, MSSP, Webinar, Next Generation ACO Model, MSSP ACO, NGACO

Complimentary Webinars: Next Generation ACOs and MSSP ACOs

Posted by Matthew Smith on Apr 9, 2015 3:37:00 PM

webinar_seriesThe implementation of the new Next Generation Accountable Care Organization (“NGACO”) model for Medicare has made it increasingly clear that ACOs will be a significant part of the government’s commitment to tie 30 percent of traditional Medicare payments to quality or value through alternative payment models by the end of 2016, and 50 percent of payments to these models by the end of 2018.

Whether your organization is just beginning to think about taking steps toward accountable care and considering the Medicare Shared Savings Program (“MSSP”); or if your organization has advanced to the point of considering the NGACO model, The Camden Group’s complimentary webinar series will provide you with background information on the programs to help you make an educated decision as to whether to participate, when to participate and which program is right for your organization.

Join us on Friday, April 17 at 12:00 p.m. ET for the first webinar in the series focusing on the NGACO program. We will discuss the specifics of this new model and the skills needed for a successful launch. Topics will include:

  • An overview of the NGACO model and the key differences between other CMS programs
  • Types of prior experience will be important for success in the NGACO
  • The included alternative payment mechanisms, and unique opportunities for network alignment
  • Next steps and logistics to consider before applying

To register for the NGACO webinar, please click the button below:

NGACO Webinar, Webinar, The Camden Group, Next Generation ACO, Accountable Care Organization

Our MSSP program will be held on Thursday, April 23 at 12:00 p.m. ET. Based on our previous application cycle and operational experience, we will discuss the specifics of the MSSP model and important items for consideration in determining if the time is right for your organization to apply. Topics will include:

  • An overview of the MSSP model and the key differences from other CMS programs
  • The changing value-based landscape and where the MSSP model fits
  • Considerations for leaders evaluating the MSSP program opportunity
  • Key elements and logistics to contemplate before applying*

*The Notice of Intent to apply is non-binding and does not commit an organization to applying. 

To register for the MSSP webinar, please click the button below:

MSSP Webinar, Webinar, The Camden Group, Accountable Care Organization

 

 

 

Our expert facilitators for the webinars include:

bosko_backgroundTawnya Bosko | Ms. Bosko is a senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment.

 

 

glaserMishka Glaser | Ms. Glaser is a manager with The Camden Group, specializing in clinical integration, accountable care, and many other innovation strategies. She brings over 15 years of experience in various sectors of healthcare including physician practices, insurance, and pharmaceuticals. Ms. Glaser’s in-depth knowledge of value-based care operations provides a context for assisting clients in navigating population health.

 

jubergDaniel Juberg | Mr. Juberg is a senior consultant with The Camden Group and focuses on clinical integration and ACOs (financial planning and funds flow modeling), Medicare Shared Savings Program applications, and strategic planning. He is also experienced in service line assessment and planning, bundled payments, CMS Innovation Center grants, medical staff needs assessments and development plans, as well as bed needs projections.

 

keberWren Keber Mr. Keber is a manager with The Camden Group and specializes in the development, implementation, and operations of clinically integrated networks (“CINs”) and accountable care organizations. He has assisted hospitals and physician organizations nationwide in achieving clinical integration and success in value-based programs. He has particular expertise in the Medicare Shared Savings Program offered by the Centers for Medicare and Medicaid Service and has advised CINs in their preparation for and participation in the program.

Topics: Accountable Care, MSSP, Webinar, Next Generation ACO Model, MSSP ACO, NGACO

Moving Forward with MSSP ACOs: Dates, Deadlines, and Opportunities

Posted by Matthew Smith on Apr 8, 2015 3:19:47 PM

savings-ahead-signWith the continued announcements by The Department of Health and Human Services (“HHS”), The Centers for Medicare and Medicaid Services (“CMS”), and other payers regarding the transition to greater value-based reimbursement, organizations must proactively assess which path is best for them. Ultimately they have to decide when to participate and how to get started. For those organizations that have already embarked on the journey (Clinical Integration [“CI”], Medicaid Accountable Care Organization [“ACO,”] etc.) the key to success is continuing to understand the models available and determine which model is best suited for the organization and/or when to participate in certain models.

As the opportunity for 2016 Medicare Shared Savings Program (“MSSP”) ACO participation draws near, organizations and leaders must decide, at the very least, if they intend to apply. The deadline for submitting a non-binding “notice of intent” (“NOI”) is May 29, 2015.

Even if organizations are remotely considering moving forward with the MSSP, they will want to submit the NOI. This does not commit an organization to submitting an application, but does hold the option open. Below are the important dates related to the 2016 MSSP ACO application process.

MSSP_Deadline_2016

Pros of Participation

MSSP ACO participation allows an organization to focus efforts on a specific, defined population for all participants and to implement tangible pieces of value-based care. Since the MSSP requirements have defined criteria around the quality measures, provider participation and incentive distribution, organizations can spend less time deciding on what initiatives to tackle and more time advancing their initiatives. This may position those organizations well for future contracts.

The physician participants may receive potential benefits in the form of care coordination resources, CMS claims data, focused quality initiatives, and potentially realizing additional income.

Cons of Participation

Although the requirements of the MSSP are not very restrictive, it is important that certain MSSP criteria exist within the provider participation agreement (“PPA”) and are executable by the organization. Since many PPAs are written to be very general, reference must be made to certain MSSP criteria--such as provider participation, incentive distribution, and provider remediation for non-compliance.

Organizations may be challenged in a couple of aspects of operations--analyzing the clinical and claims data to support quality indicators, as well as care coordination activities in order to successfully increase quality and reduce the cost of care across their population.

Evaluating the Opportunity

One common challenge for all organizations is determining when it is appropriate to move into a tangible value-based program. With the continued changes to the MSSP program and announcements from HHS, CMS and other payers regarding the continued move to value-based payments the risks of waiting to embark on the transformation journey are becoming greater.

It is important for leaders to evaluate a number of factors in determining whether an organization should participate in the MSSP. For those organizations not currently participating in a value-based program or clinically integrated network, an ACO/CI readiness assessment may be a useful first step.   

For those organizations that have already begun the transition from fee-for-service to fee-for-value, a thorough ACO/CI checkup may help organization leaders and their providers make the best decision possible while understanding their opportunities and risks. For organizations that decide to participate, such an assessment could be just the spark they need to launch their value-based program to new heights.

Regardless of what stage your organization is in, the MSSP ACO does provide a low-risk option for CINs and others to begin participating in population health management and the value-based reimbursement world.

If you have not yet downloaded The Camden Group’s 2016 MSSP Overview, please consider doing so. The file may be accessed via the button, below:

MSSP Overview, Medicare Shared Savings Program

Topics: ACO, MSSP, Accountable Care Organization, Clinical Integration, MSSP ACO

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