National Rural ACO InSRHN
>600 commercial and federal ACO’s >40 million patients receive care through ACO’s >10% of Medicare patients Physician group ACO segment has highest growth 123 more Medicare ACO’s approved in 2014 ACO Explosion Source: RUPRI Center for Rural Health Policy Analysis, 2013. Niyum Gandhi and Richard Weil, The ACO Surprise, 2012. Courtesy of Clint MacKinney, MD.
How Does “Shared Savings” Work? All existing reimbursement stays the same ACO Programs xQ $10,000 $9,500 $500 $250 $200 ACO’s Baseline Spending per Patient - based on previous 3 years, for all ACO participants ACO’s Year 1 Spending per Patient Shared Savings (50%) Quality Score Adjusted Shared Savings Savings
MSSP Benefits • Receive data on all claims submitted on your Medicare patients, regardless of point of service, to identify patient needs and be able to accurately calculate your outpatient market share, referral patterns and opportunities for new services. • Measure, report and improve on ambulatory clinical quality measures and total costs per Medicare Beneficiary to prepare for new, value-based payment models. • Valuable waivers of Stark, Patient Inducement, Anti-Trust and Anti-Kickback Statutes to enable you to align yourself with your providers, negotiate better rates with payers and demand data exchange, high quality, excellent service and cost control from your referral network. • Receive shared savings payments from CMS that should cover your costs and allow you to engage with more payers.
ACO Issues Does not include pre-application costs www.NAACOS.com
Top 5% 6-10% 11-25% 26-50% 51-100% Focus on “Top 10%” Patientsto Achieve Savings $84,293 Beneficiary Groups $35,986 $15,320 $4,381 $743
Save by Forming a Narrow Network • Focus referrals on high value providers • Develop MOU with tertiary and specialty care to: • Require data exchange and discharge notification • Avoid repeating rural diagnostics • Recognize rural medical home • Use rural health system services when feasible • Accept all patients referred, regardless of insurance type. • Provide urgent appointments within 72 hours and routine appointments within 4 weeks. • Use best efforts to provide the highest level of quality and patient satisfaction at the lowest cost. • Use and promote evidence-based medicine.
Maximize Quality Performance Poor quality scores can reduce payment up to 39%
ACO Millionaires! • Not really… • It’s more about seeing the data and funding the infrastructure than getting paid shared savings. • It will position the health system for future success by producing high quality scores and low $PBPY • Maximize future payments; • Use what you learn to negotiate with payers for additional upside; • Demonstrate value to other providers • It’s good for our patients and our community.
Future Vision • Rural communities as population health managers • 10,000 lives generate $50 million in premiums • Rural margins are 10-20% • Path • Establish expertise and actuarial data in MSSP • Add additional payers • Self-insure employees and local employers • Offer insurance on exchanges • Generate additional $5 million income/10,000 covered lives