POLICY AND PAYMENT
locked in an ongoing war of words with each other for many months now. Core to the debate is a fundamental
difference in how each side views the federal ACO ecosystem, particularly in the areas of cost savings that Medicare ACOs produce, as well as how aggres- sively the government should be push-
“We have had some time to remodel and to practice in this program. It takes an engaged group of physicians, and we do have a very large stable network of physicians who are engaged. Remodeling the incentives, transforming the care, and getting the buy-in of physicians and clinicians is incredibly important. But that does take time and it is a cultural change.” -- Gary Stuck, M.D.
ing organizations into two-sided finan- cial risk models in which Medicare isn’t on the hook for money if the ACO outspends its financial benchmarks. Comparatively, when ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains. The Medicare Shared Savings
Program (MSSP), launched in 2012, is by far the largest federal ACO model, and is inclusive of 541 ACOs that deliv- ered care to more than 11 million ben- eficiaries in 2019. Last year, these ACOs collectively generated $1.2 billion in savings for Medicare after accounting for shared savings bonuses and collect- ing shared loss payments. Nonetheless, tensions have been particularly flar- ing since late in 2018, when the Trump administration finalized its “Pathways to Success,” final regulation, an over- haul of Medicare’s ACO program that redesigns its participation options, while reducing the amount of time an ACO can remain in the program with- out taking accountability for healthcare spending from six years to two years for new ACOs, and three years for new “low-revenue” (physician-led) ACOs, including some rural ACOs. This final
rule also reduces the amount of shared savings that ACOs in upside-only risk models can collect. Put all together, the result of these
recent developments could be that many ACOs will be deterred from con- tinuing along in the program, or even participating at all, since thresholds “jump to unrealistic levels in 2021,” which will prevent them from receiv- ing a critically important 5 percent financial bonus, according to NAACOS. CMS has thus far taken the stance that if these ACOs aren’t prepared to take on more risk, and quickly, they aren’t fit for the program anyway.
The keys to ACO success In the meantime, as the feud between NAACOS and CMS continues, impor- tant lessons can be learned from those ACOs that are producing posi- tive results in the MSSP model. One such organization, Advocate Aurora Health—one of the largest integrated health systems in the U.S., serving nearly 3 million patients annually in Illinois and Wisconsin—has three affil- iated ACOs that combined to generate the most savings of any health system in the nation in the 2019 Medicare Shared Savings Program. Advocate Aurora generated $85.7 million in 2019 across its 209,000 Medicare ben- eficiaries, bringing its total savings for the federal government and taxpayers to more than $280 million since join- ing the program in 2012, the health system’s officials touted in a recent announcement.
discharging patients to the appropri- ate next care setting, ideally home if clinically appropriate; an expansion of predictive analytics and care manage- ment programs that identify patients at high risk for hospitalization or read- mission and facilitate interventions to reduce incidences of adverse and costly health events; and improvements in primary care services, preventive health services and wellness visits in alignment with a clinical integration program. Advocate Aurora’s Chief Medical
Officer, Gary Stuck, M.D., acknowl- edges that the health system has had “the luxury of time,” since they adopted the program when it first started in 2012, allowing the organization to be “early innovators.” Stuck notes, “We have had some time to remodel and to practice in this program. It takes an engaged group of physicians, and we do have a very large stable net- work of physicians who are engaged. Remodeling the incentives, transform- ing the care, and getting the buy-in of physicians and clinicians is incredibly important. But that does take time and it is a cultural change,” he admits. Indeed, the evidence is growing that
Gary Stuck, M.D. Leaders at Advocate Aurora point to
several initiatives across the organiza- tion’s continuum of care that contrib- uted to improved patient outcomes and cost savings, including: appropriate reductions in post-acute utilization; a “home-first” program driven by ACO physicians, integrated care manage- ment and post-acute teams aimed at
those Medicare ACOs that have had more time in a given program fare better than the late adopters. A 2018 analysis from consulting firm Avalere Health found that ACOs with four or more years in the MSSP accounted for nearly all of the $314 million in sav- ings the program achieved in 2017. Conversely, that analysis found, ACOs with one to two years’ experience in the program increased Medicare spending. In a recent piece on the state of ACOs in Medical Economics, Elias Matsakis, JD, senior partner of law firm Holland & Knight in Chicago, said the biggest differentiator for ACO success does truly come down to experience. ACOs that have experience in improving outcomes with efficient interventions or pathways to more appropriate sites of care fare better. Those with care coordination and chronic disease management tools will meet more quality benchmarks than will groups of providers that are essentially just rebranding themselves under an ACO label, Matsakis said. From Advocate Aurora’s perspec-
tive, the changes to the Medicare ACO program made by CMS are reasonable since success in the program requires a massive commitment to it, as well as major investments in technology and innovation. If an organization isn’t willing to do those things, it would be very difficult for them to generate
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