ACOs Flashcards
ACOs
Key Learnings for ACOs
- Need high quality data analytics
- ACO emphasis on EMR
- Importance of Economics
- ACO needs to generate savings sometime in performance period
- Importance of Planning and Understanding the Opportunity
ACOs
Requirements for ACO to be Allowed to Share Savings with CMS
- Meet Quality Standards
- Surpass Savings Hurdle Rate
ACOs
ACO Quality Standards
31 measures
- Patient/Caregiver Experience
- Care Coordination/Patient safety
- Preventive Health
- At-Risk Population
ACOs
Way for Provider Group-Based ACO to Generate Savings
- Care coordination
- Access to integrated records and consistent management
- Develop network of efficient provider
- Focus on quality results in fewer unnecessary services
ACOs
CMS Beneficiary Assignment Process
- Determine ACO Cohorts (group of partners)
- ACO submits and certifies Participant List (of finalized participating providers)
- Patients assessed against list of participating professionals to determine if ACO has provided majority of PC services to particular patient
ACOs
Uses of ACO’s Certified Participant List
- Recalculate ACO’s historical benchmark
- Determine ACO’s quality sample
- Determine performance year expenditure (shared savings/losses)
- Produce quarterly and annual feedback reports
ACOs
Criteria for Beneficiary Assigned to Participating ACO
- Record of Medicare enrollment
- At least 1 month of Part A and Part B enrollment
- No months of Medicare group private enrollment (MA)
- Assigned to only 1 Medicare shared savings initiative
- Live in US state
- Have PC service with physician at ACO
- Receive largest share of PC services from participating ACO
ACOs
Minimum Savings Rate (MSR)
ACO must generate savings of at least MSR * Benchmark to share gains
- Range from 2% (large ACOs) - 4% (small ACOs)
ACOs
Initial Benchmark Costs for Performance Year 1
ACOs
Updated Benchmark
ACOs
Rebased Benchmark
Applies to subsequent agreement periods
- Initial benchmark is adjusted for:
- Risk Scores
- Trend
- Savings generated during prior agreement period
ACOs
Medicare’s Transition to Performance-Based Risk
Advanced Alternative Payment Models(APMs)
- Involves more than nominal risk of financial loss
- Includes quality measure component
- Has majority of participants using certified EMR technology
- Includes 2-sided ACOs and PCMHs
ACOs
ACO Tracks: Shared Savings
- 1 = Up to 50%, Max = 10% of benchmark
- 1+ = 50%, 10%
- 2 = 60%, 15%
- 3 = 75%, 20%
ACOs
ACO Tracks: Shared Losses
- 1 = N/A
- 1+ = Limited to 30%, Max = 4% of benchmark
- 2 = 40-60%, 5-10%
- 3 = 40-75%, 15%
ACOs
Key Drawbacks of the MSSP Rules for Setting ACO Benchmarks
- Incentive to increase spending in last benchmark year b/c it has highest weight
- Providers that achieve savings in prior period are penalized by lower benchmark in next period
- Incentive to increase use under Medicare
