POLICY AND PAYMENT
offer their patients the personalized care that meets their individual needs.” To help identify and engage those
providers who demonstrate profi ciency in managing utilization, total cost of care, quality, and patient experience, Jackson explains that AdventHealth developed an assessment tool to gauge a provider’s level of risk-readiness. The ACO also created a preferred post-acute network, requiring participants to align with AdventHealth on quality of care and clinical measures of success while managing the length of stay and reduc- ing readmission rates. To this end, one key focus area going forward, Jackson says, is to help benefi ciaries get more of their care at home, “which we fi nd many of them prefer instead of being in a facility.” Ultimately, Jackson doubles down on the critical importance of gaining the
discounted fee-for-service payment, even as they move ahead into value- based reimbursement. Edwards notes that in the near-term, ACOs could be seen as a transitionary model to get to an end state of capitation or some form of population-based payment. But that still creates a challenge because it puts organizations in a world where they’re also living in a fee-for-service opera- tional environment. “For many of them, a large portion of
their revenue is tied to fee-for-service. So they have to figure out how to
“Taking on additional risk certainly presents challenges, [and] providers that are willing and able to participate in these programs in their early stages will be building the competencies that foster success as programs become more advanced. It’s all about providing personalized, proactive and affordable care for our patients.” -- Jennifer Jackson
Jennifer Jackson
buy-in and engagement of both clinical leaders and providers. “When we started in the program in 2018, we quickly real- ized the need for increased awareness, education and alignment. As we pro- gressed within the MSSP, we have made a concerted effort to identify and partner with our more engaged providers.”
Stakeholders ponder what’s next One massive challenge, industry-wide, that healthcare stakeholders will need to overcome as they further progress in their value-based care efforts is that most patient care organizations are still adapting to “a split-screen pay- ment landscape,” in which they will continue to receive a signifi cant portion of their reimbursement in the form of
navigate having one foot in the value- based world, and the other in the fee- for-service world,” he says. Edwards adds that once these organizations get through these ACO transitionary programs, they will get to the other side and start to get closer to fully operating on population-based payments, leading to many of them ultimately being a lot more successful. What’s more, some healthcare policy
experts believe that the future of ACOs is a bit uncertain. The highest ACO risk model, the Next Generation ACO pro- gram, was set to sunset at the end of 2020, though in light of the operational challenges brought on by the COVID- 19 pandemic, CMS has extended the
model’s final performance period through the end of December 2021. Similar to the MSSP model, ACOs in the Next Gen program, which began in 2017, have fallen short of convincing CMS that they’re substantially lower- ing healthcare costs. In a Health Affairs post earlier this year, Administrator Verma said that Next Gen ACOs in 2017 actually led to a statistically significant increase in spending of $115.6 million across the 44 participating ACOs. Another option for organizations
that will now begin in April 2021 is the Direct Contracting model, which was originally intended to be the successor to the Next Generation program before CMS extended it. Direct Contracting creates three payment options for providers to take risks and earn rewards based on quality outcome, and leverages lessons learned from other Medicare ACO initiatives. Premier’s Edwards says one organi-
zation the PHMC is working with that has been in the MSSP is now looking at evaluating whether or not to par- ticipate in the new Direct Contracting model. The reason being, he says, “is that they want to move their primary care clinicians to a capitated arrange- ment, because they don’t believe that the fee-for-service/RVU approach is congruent with the goals of being in a Medicare ACO. They believe they can be a lot more successful by aligning those incentives for their payment to that capitated model where they can use those dollars to really manage the patients in a way that will be most meaningful and impactful for their patients.” In the end, regardless of the speed of
the regulatory engine, the value-based care train is moving, and those who haven’t gotten on board yet will need to—or they’ll be left behind. “Taking on additional risk certainly presents challenges, [and] providers that are willing and able to participate in these programs in their early stages will be building the competencies that foster success as programs become more advanced,” AdventHealth’s Jackson contends. Ultimately, she adds, “It’s all about providing personalized, proactive and affordable care for our patients.” HI
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