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The Transformers: ACO’s, Bundled Payments and Implications for Physician Practice. Stuart J. Glassman, MD, FAAPMR Clinical Assistant Professor, Geisel School of Medicine at Dartmouth Clinical Instructor, Tufts University School of Medicine President, Granite Physiatry , PLLC, Concord, NH. - PowerPoint PPT Presentation
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STUART J. GLASSMAN, MD, FAAPMRCLINICAL ASSISTANT PROFESSOR, GEISEL
SCHOOL OF MEDICINE AT DARTMOUTHCLINICAL INSTRUCTOR, TUFTS UNIVERSITY
SCHOOL OF MEDICINEPRESIDENT, GRANITE PHYSIATRY, PLLC,
CONCORD, NH
The Transformers: ACO’s, Bundled Payments and Implications for
Physician Practice
Concord Hospital/Capitol Region Health Care (Concord, NH)
New CEO (Robert Steigmeyer) came from Geisinger Community Medical Center
Non-profit, Level 3 Trauma Center, 295 Beds
Dartmouth Hitchcock Medical Center/Geisel School of Medicine (Lebanon, NH)
Level 1 Trauma Center, 396 bedsCEO/President—Dr. James Weinstein
(Orthopedics/Spine Care)Health System/Clinics serve 1.5 million
population in NH and Vermont
Accountable Care Organizations
What's an ACO?--Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients (www.cms.gov)
Incentive payments for cost-effective healthcare outcomes
ACO Categories
Medicare Shared Savings Program—a program that helps a Medicare fee-for-service program providers become an ACO
Advance Payment ACO Model—a supplementary incentive program for selected participants in the Shared Savings Program
Pioneer ACO Model—a program designed for early adopters of coordinated care
ACO’s must manage 5,000 Medicare beneficiaries for at least 3 years (Obamacare)
ACO Data 2014
Currently over 600 ACO’s in the United States (CMS/government contracts, private commercial ACO’s)
Over 20 million lives covered--www.leavittpartners.com
CMS indicates over $372 million in shared savings for ACO programs, with improvements in quality data reporting
ACO penetration map:
Business Issues in Health Care Delivery Systems
Bundled Payments for Care Improvement Initiative (BPCI)
Announced by CMS Jan. 31, 2013Organizations will enter into payment
arrangements that include financial and performance accountability for episodes of care
4 Models of Bundled Payments
Model 1: Retrospective Acute Care Hospital Stay Only
Under Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule..
Bundled Payment Model 2
Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care
In Model 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end either 30, 60, or 90 days after hospital discharge. Participants can select up to 48 different clinical condition episodes.
Bundled Payment Model 3
Model 3: Retrospective Post-Acute Care OnlyFor Model 3, the episode of care will be triggered
by an acute care hospital stay and will BEGIN at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. Participants can select up to 48 different clinical condition episodes.
Bundled Payment Model 4
Model 4: Acute Care Hospital Stay OnlyUnder Model 4, CMS will make a single,
prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.
Triple Aim (cont.)
Has 3 simultaneous areas of focus:1. Improving the health of populations2. Improving the patient experience of care
(including quality and satisfaction)3. Reducing the per capita cost of health careEmphasis on evidence-based medicine
outcomes and comparative scientific research for healthcare decisions
Patient Centered Medical Home
Patient-Centered Medical Home Recognition The patient-centered medical home—one of modern health
care’s most important innovations—is a model of care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” NCQA Patient-Centered Medical Home (PCMH) Recognition is the most widely-adopted model for transforming primary care practices into medical homes.
Clinicians, insurers, purchasers, consumer groups and others know the patient-centered medical home is a proven alternative to the nation’s costly, fragmented delivery system. Research confirms that medical homes can lead to higher quality and lower costs, and can improve patient and provider experiences of care
Accountable Care Organizations in NH (2013)
Pioneer ACO—Dartmouth Hitchcock ACO (NH/VT)Granite Healthcare Network/CignaNorth Country ACO (Littleton, NH)New Hampshire Citizens Health Initiative
Accountable Care ProjectConcord Elliot ACO LLC (Medicare Shared
Savings Program)Northern New England Accountable Care
Collaborative (Maine, NH, Vermont)ElevateHealth (Shared-Risk Arrangement between
Harvard Pilgrim, DHMC and Elliot Hospital)
Accountable Care Organizations in NH (2014)
Lahey Clinical Performance Accountable Care Organization, LLC
OneCare Vermont Accountable Care Organizations, LLC
The Premier Health Care Network, LLCWinchester Community COCircle Health Alliance, LLCNew Hampshire Accountable Care Partners ACODarmouth-Hitchcock ACONorth County ACO
NH Accountable Care Partners ACO
Made up of 4 health systems—Concord Hospital, Elliot Health System, Southern NH Health System, Wentworth-Douglass Health System
Based in Concord, NH965 Health Care providersCover 40,000 Medicare beneficiaries
A Cautionary Tale—Where Is Rehab?
NO involvement of PM&R at any leadership level in the various ACO’s
Lack of involvement in Post Acute Care Committees
Most physiatrists in NH are NOT employed by hospital systems—are we outside looking in?
NH has 2 IRF hospitals (Concord, Salem), 3 IRF units (Manchester, Nashua, Keene), 4th to open in March 2015;various SNF level facilities (Genesis), NO LTACH
No PM&R residency
PM&R in the Brave New Healthcare World
Post Acute Care Issues and Outcomes within ‘shared care dollars’—Variable Care costs? (IOM variation was 73%)
Based on patient needs, NOT patient location (2012 Medicare post acute care costs: $62B)
Functional Outcomes and Quality of Life Measures in ACO’s; 2 separate bundled payments (Acute/Post Acute Care)
Physician Practice Concerns in ACO/Bundled Payment Models
Upside only risk: Medicare Shared Savings, Medicare Advantage—no penalties if physician/hospital does not meet savings goal; can get bonuses if goals are met; up to 60% of savings goes to physician/hospital (one-sided risk)
Downside risk—hospitals/physicians lose money if savings goals are not met (two-sided risk)
Flat management fee—no bonus if savings goals are met (fee usually $3 to $5/month per patient)
Public versus private payors—much more downside risk with private payor ACO; can’t tolerate losses in early years of the program
Contracts may switch from one-sided to two sided after a few years
Risk Versus Reward
Loss of practice independence when joining an ACO
Significant financial up-front costsRisk of exclusivity (usually for PCP’s) in a
single ACOBalance of quality measure outcomes and
cost savings generated (CMS Shared Savings program has 33 quality measures for reporting)
PCP’s will likely want to have routine follow up care stay within their offices and NOT refer to specialist physicians
Global Risk Contracting
Becoming popular in Minnesota and Massachusetts
Fixed-dollar payment amounts per patient for a specified time period (one month, one year)
Large incentive on controlling costsBundled services at the patient level, not the
episode of care levelMay include supplemental payments based
on quality measure outcomes
Avoiding Specialist Exclusivity Clauses
ACO exclusivity analysis focuses on whether ANY physician in a single-specialty or multispecialty group practice provides services under E&M codes for office, outpatient, home or nursing facility visits, and whether the Medicare patient sees a PCP during the applicable time period
Must be careful to avoid triggering the ACO exclusivity clause, which will limit the specialist to that ACO only
Specialists should encourage patients to see their PCPConsider providing services under a separate entity
that bills under a separate TIN (federal tax ID number)
Bundled Payments
Covers payments to 2 or more providers during a single episode of care or over a specific period of time
Already seen in ‘global surgery periods’‘Actual’ bundle—single payment to one entity (i.e.
ACO) which then splits up the payment to multiple physicians
‘Virtual’ bundle—the payer makes payments to multiple providers, based on the negotiated pre-defined rules of the contract
It IS risk-contracting; physicians should know how payments and risk adjustment factors are calculated
Bedford (NH) ASC/Harvard Pilgrim Healthcare Bundling Pilot Program
Applies to routine colonoscopies—bundled payment for surgeon, anesthesiologist, facility and pathologist
44 patients participated in the first quarter of 2014
Has a built in 5% price discountFollows quality metrics from the American
College of Gastroenterology (number of screening that identify polyps/cancer, type of anesthesia used)
Post-Acute Care Services and the Triple Aim
$62 billion spent in 2012 by Medicare on post-acute care services (11% of Medicare outlays)
IOM report shows that there is a 73% variation in total Medicare spending due to utilization of PACS
Hospital referral regions (HRRs) with high PACS also have the highest overall spending
Quality Outcome Measures for ACO’s in 2015 will likely add in a ‘SNF 30 day “all-cause” readmission’ quality metric
Improved patient outcomes do correlate with appropriate PAC utilization (SNF, IRF, Home Health, LTCH)
Engagement Spectrum of ACO’s and PAC Providers
Minimal—no formal engagement. ACO informs physicians of their referral patterns
Conditional Collaboration—shared standards, protocols and data utilization; stay within preferred provider network
Partnership—shared quality metrics and discharge data; have ‘care transition coordinators’
Financial and Data Integration—PAC provider has access to EHR; shared financial risk; share technology
Full Integration—PAC providers are owned by ACO
Coordinated Model of Acute and Post-Acute Care
Integrated-Care markets—full array of PAC servicesTransitional hospital care (LTACH), short-term
rehabilitation (IRF), sub-acute, skilled nursing, home health, palliative care, hospice
Joint ventures for bundled payments initiative (i.e. Cleveland Clinic)
Manage the transition of care for the patient, improve outcomes, decrease costs
Attractive to payers, ACO’s and hospital systemsExample—Kindred Healthcare Inc. (Louisville, KY;
KND; annual revenue $5B;
What Does the Physiatrist Bring to the ACO/Bundled Payment Table?
Ability to work within a team formatFocus on functional, Triple-Aim outcomesUnderstanding of care transitions in the post-acute
worldAbility to treat multiple organ system issues (brain,
spine, musculoskeletal, cardiac) and disease states (diabetes, CHF, cancer, pain, obesity, asthma)
Understanding of Durable Medical Equipment needs
YOU MAY HAVE TO CRASH THE PARTY—the ACO leaders may not understand what we do!!