ACO Explosion

Bill Demarco, October 1, 2012

Medicare Shared Savings

Feasibility studies for three ACOs in North Carolina, a medical group in Arizona, a physician alliance in Illinois, a hospital system in Indiana and consultation with several Pioneer Plans has kept us very busy over the last several months. Most of these are physician owned medical groups, while several are IPAs with medical homes who want to collaborate with one another to form the primary care base of a Medicare Shared Savings ACO.

Over 490 applications for new ACOs are in process and due to CMS by September 6th. Add to this the several hundred earlier ACOs approved in April and June of this year and it becomes clear that the 600% growth rate in ACOs since November of last year when final rules were published brings excitement to the marketplace.

This easily represents 20% of Medicare beneficiaries who will be connected to Medicare through their ACO by January 1, 2013. When adding the Medicare Advantage beneficiaries that represent 27% of the Medicare population and growing, it is a factual statement to say that 50% of all Medicare beneficiaries will be receiving their benefits through Medicare contractors instead of Medicare directly. These contractors are all being held accountable by CMS to follow stringent guidelines including patient satisfaction.

This means Medicare has been permanently changed by focusing on shares savings for improving quality instead of merely paying claims. We anticipate ACO mergers and acquisitions will be the next step as investors and hospitals catch up to the opportunity to invest in the new chronic care business model.

We are excited for the plans with whom we have worked and their enthusiasm and innovation encourages us to expand our own resources and capabilities to serve this emerging transformation of the local delivery system.

Cautioning new applicants for next spring

We are talking to people about getting their Notices of Intent (NOI) submitted in the spring. This would make them eligible for submitting an application in fall of 2013 with a start date of January 1, 2014.

Applications that look simple are not acceptable by CMS with simple answers. Some of the key points we have heard from CMS include:

• Several workflow adjustments need to be made to make the patient process coordinated and all encompassing.

• Early charge reconciliations indicate the patient population notified by CMS may be different than the original ACO defined population discussed in early planning.

In addition, beneficiary engagement is a vital area of the application and connects with population management which is the backbone of successful care management. Tools and techniques vary by service area.

What’s an AHO?

What is the difference between a Medicare Shared Savings ACO and an Accountable Health Organization (AHO)? Is an AHO a private ACO?

Many people continue to be confused by private ACOs such as those sponsored by Cigna, Aetna and Blue Cross versus the Medicare Shared Savings opportunity to contract for Medicare lives in their area. While many of these private ACOs represent more of a bundled payment experiment paying global fees to doctors and hospitals tied to some sort of risk banding, the Medicare ACOs have a stronger focus on quality scores versus production of services and in so doing are able to raise the bar for both quality and cost. Private ACO sponsors are slowly making this transition but providers need to read closely what they are obligating themselves to in the future. Some are asking insurers for 2 side risk on day one and some are asking for one side risk only.