ACOs/Shared Savings Demonstration Project: What Does It All Mean? None Conflicts of Interest Sean P. Roddy, MD Albany, NY Accountable Care Organizations Term introduced in 2006 by Fisher et al. the hospital and its extended medical staff provide a natural organizational setting within which to improve the overall experience of care Affordable Care Act in 2010 mandated development of a Medicare shared savings program by June 1, 2012 ACO Model Why The Demonstration Project? Create incentives for healthcare providers to work together to treat each patient across care settings Doctor s offices Hospitals Long-term care facilities Avoid the presumed fragmented care seen using fee-for-service with disconnected payments Alter the paradigm where doctors & hospitals are compensated more by testing & procedures 1
CMS Shared Savings Program Goals Final SSP rule published November 2, 2011 1. Promote accountability for the care of Medicare beneficiaries 2. Require coordinated care for all services provided under Medicare 3. Encourage investment in infrastructure and redesigned care processes Medicare ACO - Payments Providers will initially receive payment under Medicare Fee-For-Service rules Initially, pay for reporting (like PQRS at present) Thereafter, pay for both reporting & performance Before an ACO can share in savings, it must demonstrate the quality standard for that year In latter years, part or all of the payments will transition to a population-based model ACO Quality Measures Developed A major concern with ACOs is the potential for withholding care or lowering quality care in order to achieve financial gain On one hand, savings can be seen by not consulting additional specialty physicians or ordering additional testing On the other hand, ACO quality measures must be achieved to qualify for the shared savings E.g., hemoglobin A1C levels, etc. 33 ACO Quality Measures Four Domains - Equally Weighted Patient/caregiver experience (7 measures) Care coordination/patient safety (6 measures) Preventive health (8 measures) At-risk population: Diabetes (6 measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) Coronary Artery Disease (2 measures) 2
33 Quality Measures 7 are collected via patient survey 3 are calculated via claims data 1 is calculated from Medicare Electronic Health Record (EHR) Incentive Program data 22 are collected via the ACO Group Practice Reporting Option (GPRO) Web interface Only 23 measures are scored The patient experience survey modules are scored as 1 The all-or-nothing diabetes / CAD measures are each 1 Quality Measures Quality Performance Score Each domain given equal weight (25% of total score) In each domain, individual measures equally weighted Failure to achieve the quality performance standard in 70% of the measures in each domain will result in a corrective action plan and reevaluation in the following year If an ACO scores a zero for an entire domain, it will not be able to share in the savings generated Medicare Options For ACO Medicare Shared Savings Program A program that helps a Medicare fee-forservice program providers become an ACO Advance Payment ACO Model Supplementary incentive program for selected participants in the Shared Savings Program Pioneer ACO Model Designed for early adopters of coordinated care No longer accepting applications Medicare Shared Savings Program 5,000+ Medicare Fee-For-Service patients Participation for at least 3 years Each ACO must establish a governing body to: Develop processes to promote evidence-based medicine Promote patient engagement Internally report on quality and cost Coordinate care If no savings achieved, no significant MD risk 3
Advance Payment ACO Initiative Potential for some organizations to receive some upfront payments to help fund development of the program in the start up phase CMS will recoup these advance payments from an ACO s shared savings Eligibility CMS favors low total annual revenue, critical access hospitals, and rural locations Advance Payment ACO Why? To assess whether providing an advance (in the form of upfront payments to be repaid in the future) will increase participation Will advanced payments: Allow ACOs to improve care for beneficiaries Generate Medicare savings more expeditiously Increase the actual amount of Medicare savings Advance Payment ACO Payments An upfront, fixed payment Each ACO will receive a fixed payment. An upfront, variable payment Based on # of historically assigned beneficiaries A monthly payment of varying amount depending on the size of the ACO Based on # of historically-assigned beneficiaries Pioneer ACO 32 organizations were selected nationally Began January 1, 2012 Higher levels of both risk and reward First two years require comparison to historical controls for the 670,000 seniors In year three if savings are realized, the ACO is eligible for population-based payment per month to replace all or some fee-for-service 4
Pioneer ACO Reported 1st Year Performance July 2013 Quality measures results Outperformed fee-for-service in 15 clinical measures 25 of 32 ACOs reduced risk-adjusted readmissions 13 shared in savings & 1 had a shared loss 18 were either below the threshold for sharing or not at risk for loss Nine abandoned in the first year Two groups left ACO Demonstrations altogether Seven groups pursuing an alternative ACO model after failing to produce savings Second Phase of the ACO Programs CMS should issue regulations in 2014 to address various areas of concern: One-side risk versus two-side risk Setting Benchmarks Beneficiary assignment Cost for operating ACO is 1-2% while savings is 0.5% Second Medicare Shared Savings Program ACO cycle to start in 2015 Pioneer ACO Demos move to population-based payment in 2014 Alternative Payment Models (APMs) ACOs are more focused on primary care Request for Information sent out by CMS on Specialty Payment Models SVS HPC is reviewing potential options Creation of a usable AV access Enrollment in an APM key to new bills Bonus payments if a significant share of revenue MD then excluded from the MIPS assessment 5
Impact on Vascular Surgeons Incentives change from volume to quality Current quality measures do not generally apply to vascular surgery at the mercy of other specialties for gain or loss Obligation to validate each surgical procedure will rest on the vascular surgeons Evidence to perform the procedure Quality metrics associated with the operation Conclusions ACA has mandated testing of ACO models SVS will analyze and comment on any new ACO proposed regulations and APM programs Outcomes are still pending with significant concerns over the required benchmarks / cost Vascular surgeons are at the mercy of the primary MDs for gain/loss in the ACO The SVS must lead efforts to demonstrate necessity and quality measures for vascular interventions both open and endovascular 6