Transcript Accountable Care Organizations, Part 3 of 3

Accountable Care
Organizations
(ACOs)
Part 3 of 3
Migena Peno
Pharm.D. Candidate
LECOM School of Pharmacy
Measures for at risk population
DIABETES CARE:
CORONARY HEART
DISEASE
1. HbA1c control <8%
1. Treatment for high LDL-C
2. LDL-C <100 mg/dL
2. ACEI or ARB if CAD +
DM +/- left ventricular
systolic dysfunction
3. BP<140/90 mm Hg
4. Tobacco non-use
5. Aspirin prophylaxis use
6. Poor HbA1c control >9%
ISCHEMIC HEART DISEASE
1. Complete lipid profile
2. LDL-C control <100 mg/dL
Centers for Medicare & Medicaid Services. Medicare Program; Medicare Shared Savings Program: Accountable Care
Organizations. 42 CFR Part 425. Final Rule.
Measures for care
coordination & patient safety
 Important for prevention of hospital readmissions
 Includes:
 Risk-adjusted, all-condition readmission
measure
 Measures for admissions from ambulatory
sensitive conditions : COPD & CHF
 Medication reconciliation after discharge from
inpatient facility
Centers for Medicare & Medicaid Services. Medicare Program; Medicare Shared Savings Program: Accountable Care
Organizations. Final Rule. Fed Regist. 2011;76(2):67802-67990 (codified at 42 CFR Part 425).
Role of different health care
providers in cost reduction & quality
improvement
 Primary Care practices
 Improved access to care
 Prevention
 Early diagnosis
 Reduction in unnecessary testing, referrals, &
treatment
 Selection of lower-cost treatment options
 Reduction in ER visits & hospitalizations
 All providers
 Improved management of complex patients with
multiple disease states
Capgemini Consulting. US Health Care Reform: The Emergence of Value Based Purchasing and Accountable Care
Organizations. 2011.
Role of different health care
providers in cost reduction & quality
improvement
 All providers
 Lower-cost more accessible settings & care
delivery methods
 Use of lower-cost, high-quality providers
 Coordinated health & social services support
 Hospitals & Specialists
 Improved efficiency of patient care
 Reduction in readmissions
 Reduction in adverse & sentinel events
 Selection of lower-cost treatment options
Capgemini Consulting. US Health Care Reform: The Emergence of Value Based Purchasing and Accountable Care
Organizations. 2011.
Methods ACOs generate shared savings
 Reduction of unnecessary OR duplicative services
 Development of care protocols
 Improve coordination of care
 Improve management of disease states
 Increase preventive services
 Encourage early diagnosis
 Improve information flow
 Promote lower-cost treatment options
 Scale purchasing of goods & services
 Reduction in preventable ER visits & re-
hospitalizations
 Hiring specialists to optimize efficiency
 Efficient use of resources
Some ACO activities may have antitrust or other legal and regulatory constraints, which are beyond the scope of this
report.
Value-Based Purchasing (VBP)
 Links payment to quality of care
 Rewards providers that show improved performance
 Performance: based on a set of quality measures that
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are related to improved clinical processes of care &
patient satisfaction
Reduces inappropriate care
Encourages improvements in quality of care resulting
in additional savings over time
Main focus: Best clinical practices & patient’s
experience of care
Hospitals scored based on performance relative to
other hospitals & improvement in performance over
time
Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs. Healthcare.gov
Value-Based Purchasing (VBP)
 In 2013, 1% reduction in hospital payment for care
provided to Medicare patients to create funding for
VBP
 Reduction in payment will be increased by 0.25%
annually until reaching maximum 2% in 2017
 Starting 2013, hospital payment reduced if excess 30day readmissions for patients with heart attacks, HF,
& PNA
 In 2013, ~ $850 millions from the money saved to
Medicare will be distributed among 3,500 hospitals
based on their overall performance
Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs. Healthcare.gov
Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Value-Based Purchasing Program.
Final Rule. Fed Register. 76;26490-26547
Value-Based Purchasing (VBP)
 Performance based on:
 12 clinical process of care measures (70% of
hospital’s total performance score)
 Includes: HF discharge instructions, acute MI &
PNA care, healthcare-associated infections, &
surgical care improvement
 8 patient experience measures (30% of hospital’s
total performance score) derived from HCAHPS
 Includes: Measures related to discharge
information & communication about
medications
Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Value-Based
Purchasing Program. Final Rule. Fed Register. 76;26490-26547
Value-Based Purchasing (VBP)
 Starting 2014, in addition to clinical process &
patient experience, performance score will also
include outcomes & efficiency
 Outcome measures implemented in 2014
 Includes: Mortality rates for heart attacks, HF
& PNA, hospital-acquired conditions, &
patient safety indicators
 Efficiency measures implemented in 2014
 Includes: Cost per beneficiary
Studer Group. Value-based purchasing at a glance.
Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Value-Based Purchasing Program.
Final Rule. Fed Register. 76;26490-26547
Benefits of ACOs
 Less medical errors & duplication of services
 Reduced hospital admissions
 Shared information among providers participating in
ACOs reduces burden of transferring information,
reduces errors, & improves quality of care
 Improved communication & coordination of care
among different health care providers
 Keeping patients healthy by encouraging preventive
care
Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs. Healthcare.gov
Newman, D. Accountable Care Organizations and the Medicare Shared Savings Program. Congressional Research
Service. Nov 4, 2010
Benefits of ACOs
 Health care providers are accountable for entire
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continuum of care, from primary to post-acute
Performance measures ensure improvement in quality
of care
Coordinated care among providers involves
integration of providers across different care settings
Primary care is emphasized
Improved outcome, quality of care, & patient
experience
Newman, D. Accountable Care Organizations and the Medicare Shared Savings Program. Congressional Research
Service. Nov 4, 2010
Benefits of ACOs
 Estimated to save Medicare up to $960 millions in the
1st 3 years
 Savings are not at the cost of quality
 Shifts some of the responsibility for costs from health
insurers to health care providers
 Does not require Medicare beneficiaries actually join
a health plan
Newman, D. Accountable Care Organizations and the Medicare Shared Savings Program. Congressional Research
Service. Nov 4, 2010
Harold D. Miller, How to Create Accountable Care Organizations, Center for Healthcare Quality and Payment Reform,
Pittsburgh, PA, September 7, 2009.
The House Tri-Committee’s proposal, the America’s Affordable Health Choices Act of 2009, required that
beneficiaries be informed of their assignment to an ACO, whereas the Senate Finance Committee’s America’s Healthy
Future Act of 2009 did not stipulate that beneficiaries be informed. See Kelly Devers and Robert Berenson, Can
Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries? Robert Wood
Johnson Foundation and Urban Institute, Washington, DC, October 2009, p. 6
Limitations of ACOs
 Must have the necessary capital to initiate the
program at the individual facility, making it harder
for individual providers to join
 Gives provider groups power to negotiate rates of
reimbursement which can increase payment for
private insurance even if less efficient care is
provided
 Medicare Shared Savings Program only includes
items & services under Medicare Part A & B while
Medicare Part D is excluded
Newman, D. Accountable Care Organizations and the Medicare Shared Savings Program. Congressional Research
Service. Nov 4, 2010
Robert A. Berenson, Paul B. Ginsburg, and Nicole Kemper, “Unchecked Provider Clout in California Foreshadows
Challenges to Health Reform,” Health Affairs, vol. 29, no. 4 (April 2010), p. 700.
Francis J. Crosson, “Medicare: The Place to Start Delivery System Reform,” Health Affairs, Web Exclusive January 27,.
2009, pp. W232-W234.
Limitations of ACOs
 Limited data on whether ACOs actually work
 Performance measures increase burden of work
(reporting, auditing, chart reviews, etc) & cost, & are
not always accurate or reliable
 Potential for increase in prices by providers not
participating in ACO
Fisher E, Shortell S. Accountable Care Organizations: Accountable for What, to Whom, and How. JAMA Oct 20,
2010 Vol 304, No. 15
Newman, D. Accountable Care Organizations and the Medicare Shared Savings Program. Congressional Research
Service. Nov 4, 2010
Summary