Center for Medicare and Medicaid Innovation & ACOs
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Transcript of Center for Medicare and Medicaid Innovation & ACOs
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Creation of the Center for Medicare and Medicaid Innovation & ACOsAdele Allison,National Director of Government Affairs, SuccessEHS
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Created under §3021 of Patient Protection & Affordable Care Act
$10 Billion allocated for FY2011 - 2019
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Focus on Government Health Programs
Medicaid, Medicare, Children’s Health Insurance Program
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Empowered by Congress
-Flexibility in selecting and testing new payment models-Secretary allowed broad discretion in rulemaking
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Spotlight on decreased costs & increased quality
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Four Mission Domains1. Patient Care Models
-Bundled Payments2. Seamless & Coordinated Care Models
-ACOs & PCMHs
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Four Mission Domains3. State Engagement Models
-1,200 medical homes; Medicaid Health Home State Plan (2 years 90% funded for chronic dz. or mental illness)4. Community & Population Health Models
-Public Health (ex: smoking, obesity)
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CMMI & ACOs
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PPACA requires CMS to start contracting CY2012
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What is an Accountable Care Organization (ACO)?“Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.”
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Three types of CMMI ACOs1. Shared-Savings ACO2. Advanced Payment ACO3. Pioneer ACO
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ACO Final Rule: Applications open Jan. 1, 2012
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Two initial launch dates: April 1, 2012 &July 1, 2012
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CMS anticipates 270 ACOs to form
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Medicare Shared-Savings ACO
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Heart of the ACO Final Rule issued Oct. 20, 2011
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Minimum 5,000 Medicare PFS Beneficiaries
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Two ModelsOne-Sided, No Risk = 50% sharing in savings created
Two-Sided, Limited Risk = 60% sharing in savings created
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One-Sided-Physicians paid FFS, as usual-If savings is created AND performance measures achieved, 50/50 split-If ACO exceeds per capita benchmark, no downside
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Two-Sided-Physicians paid FFS, as usual-If savings is created AND performance measures achieved, 60/40 split-If ACO exceeds per capita benchmark, fee adjustment occurs (capped)
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Advanced Payment ACO
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Created to help MD-owned and/or Rural Providers
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Limited to Two Organizational Types 1. ACOs with no inpatient and annual revenue of < $50 million2. ACOs with inpatient through CAHs/Rural hospitals and revenue of < $80 million
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Three Payment Types1. Upfront Fixed Payment2. Upfront Payment based on historically-assigned beneficiaries3. Monthly Payment based on historically-assigned beneficiaries
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ACO application must be made for both Shared-Savings and Advanced Payment
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No health plan ownership allowed
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Pioneer ACO
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Created for Advanced Health Organizations
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Minimum 15,000 aligned beneficiaries
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Not subject to the ACO Final Rule – Separated Model
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Intent of the Model-Allow advanced systems to move quickly to population-based payment model
-Work in coordinating model with private payers to align quality and outcome incentives
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Pioneers would have a higher share in savings created
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Pioneers also have a higher share in risk
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Pioneers have broadened control over community-based rewards and consequences
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