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Accountable Care Organizations (ACOs)
1. Accountable
 Care
 Organiza2ons
 (ACOs)
Â
Wednesday,
 January
 29,
 2014
Â
Disclaimer:
 Nothing
 that
 we
 are
 sharing
 is
 intended
 as
 legally
 binding
 or
 prescrip7ve
 advice.
 This
 presenta7on
 is
 a
Â
synthesis
 of
 publically
 available
 informa7on
 and
 best
 prac7ces.
Â
2. Accountable
 Care
 Organiza,ons
Â
(ACOs)
Â
â˘âŻ Builds
 oďŹ
 Pa,ent-ÂâCentered
 Medical
 Home
Â
â⯠Coordinated
 care
 to
 ensure
 seamless
 transi,on
Â
between
 services
 and
 levels
 of
 care
Â
â˘âŻ Formalizes
 Pa,ent-ÂâCentered
 Medical
Â
Neighborhoods
Â
â⯠Brings
 together
 primary
 care
 physicians,
Â
specialists,
 and
 hospitals
Â
â˘âŻ Reimbursement
 amount
 linked
 to
 quality
Â
â˘âŻ Launched
 in
 2012
Â
3. ACO
 Overview
Â
â˘âŻ Model
 for
 delivery
Â
â˘âŻ Voluntary
 virtual
 conglomerate
Â
â⯠For
 providers
 serving
 Medicare
 beneďŹciaries
Â
â⯠Shared
 responsibility
 amongst
 coordinated
 healthcare
Â
providers
Â
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
High
 quality
 care
Â
Curtailing
 growth
 of
 healthcare
 costs
Â
Shared
 accountability
 for
 pa,ent
 health
 outcomes
Â
Comba,ng
 overu,liza,on
 of
 healthcare
 services
Â
Improved
 value
 of
 care
Â
â⯠Financial
 incen,ve
 from
 money
 saved
Â
4. Key
 Design
 Features
 of
 an
 ACO
Â
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Accountability
Â
Organiza,on
 and
 Governance
Â
Primary
 care
 focus
Â
SuďŹciently
 sized
 pa,ent
 popula,ons
Â
Investment
 in
 delivery
 system
 improvement
Â
Shared
 saving
Â
Performance
 Measurement
Â
5. Success
 Criteria
 for
 ACOs
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Leadership
Â
Teamwork-Ââoriented
 organiza,onal
 structure
Â
Synergis,c
 provider
 rela,onships
Â
IT
 infrastructure
Â
â⯠Popula,on
 analy,cs
 and
 management
Â
â⯠Coordina,on
 of
 care
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Quality
 indicators
Â
Financial
 risk
 management
Â
Pa,ent
 educa,on
 and
 support
Â
Financial
 infrastructure
Â
6. Fundamentals
 of
 an
 ACO
Â
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Leadership
Â
Organiza,onal
 commitment
Â
Upfront
 investment
Â
Informa,on
 ďŹows
 and
 technology
Â
Care
 management
 strategies
Â
7. ACO
 Technology
 Infrastructure
Â
Enterprise
 Revenue
Â
Â
Cycle
 Management
Â
Electronic
 Health
Â
Â
Record
Â
Â
Â
Â
Pa,ent Engagement
Informa,cs
Â
Health
 Informa,on
Â
Exchange
Â
8. Technology
 Considera,ons
Â
Pa,ent
Â
Engagement
Â
Data
Â
Aggrega,on
Â
Popula,on
Â
Health
Â
Management
Â
Privacy
 and
Â
Security
Â
Clinical
 and
Â
Administra,ve
Â
Date
 Exchange
Â
Performance
Â
Management
Â
Repor,ng
Â
Infrastructure
Â
Finances
Â
9. Startup
 Costs
Â
â˘âŻ Startup
 costs
 reported
 by
 the
 Na,onal
 Associa,on
 of
Â
Accountable
 Care
 Organiza,ons
 (NAACOS)
Â
â⯠Average:
 $
 2
 million
Â
â⯠Range:
 $300
 thousand
 -Ââ
 $
 6.7
 million
Â
â⯠Excluding
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Feasibility
 studies
Â
CMS
 applica,on
Â
Legal
 fees
Â
Â
Other
 pre-Ââcontract
 costs
Â
Â
â⯠Higher
 than
 CMS
 es,mate
 ($1.8
 million)
Â
â⯠Less
 than
 AHA
 es,mate
 ($11.6
 to
 $26.5
 million)
Â
â⯠Financial
 risk:
 $
 4
 million
 in
 ďŹrst
 year
Â
10. Startup
 Cost
 Categories
Â
Network
Â
Development
 and
Â
Management
Â
Human
 Resources
 and
Â
compensa,on
Â
Â
Care
 Coordina,on,
Â
Quality
Â
Improvement,
 and
Â
U,liza,on
Â
Management
Â
Disease
 registries
Â
Clinical
 Informa,on
Â
Systems
Â
EHR
Â
Legal
 and
 consul,ng
Â
support
Â
Financial
 and
 MIS
Â
systems
Â
Recruitment
 and
Â
restructuring
Â
Care
 paeern
 analyses
Â
Care
 Coordina,on
Â
intra-Ââsystem
 EHR
Â
Disease
 Management
Â
Strategic
 partnerships
Â
Post-Ââacute
 care
Â
Data
 Analy,cs
Â
Quality
 Repor,ng
Â
PCMH
 Cer,ďŹca,on
Â
HIE
Â
11. Startup
 Costs
 by
 BeneďŹciaries
Â
Es2mated
 Start
 Up
 Costs
Â
3,000,000
Â
2,500,000
Â
2,000,000
Â
1,500,000
Â
1,000,000
Â
500,000
Â
0
Â
5,000
 -Ââ
 15,000
Â
16,000
 -Ââ
 25,000
Â
Aligned
 BeneďŹciaries
Â
26,000+
Â
12. Costs
Â
IT
 Costs
Â
1,000,000
Â
900,000
Â
800,000
Â
700,000
Â
600,000
Â
500,000
Â
400,000
Â
300,000
Â
200,000
Â
100,000
Â
0
Â
Internal
 IT
Â
External
 Vendor
Â
5,000
 -Ââ
Â
10,000
Â
10,000
 -Ââ
Â
15,000
Â
15,000
 -Ââ
Â
25,000
Â
Aligned
 BeneďŹciaries
Â
26,000+
Â
13. Es,mated
 Savings*
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Â
13
 ACOs
 broke
 even
Â
9
 ACOs
 gained
 an
 average
 $1.3
 million
Â
6
 ACOs
 lost
 an
 average
 of
 $1.3
 million
Â
6
 ACOs
 did
 not
 know
 or
 did
 not
 report
Â
Â
* Source:
 Na7onal
 Associa7on
 of
 Accountable
 Care
 Organiza7ons
 (NAACOS)
14. Opera2onal
 Challenges
Â
Other
Â
22%
Â
CMS
 Data
Â
40%
Â
Out
 of
 Network
Â
Use
Â
7%
Â
Quality
 Repor,ng
Â
11%
Â
Governance
Â
9%
Â
IT
 Opera,ons
Â
11%
Â
15. ACO
 Accredita,on
Â
â˘âŻ NCQA
Â
â⯠Standards
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
Pa,ent
 access
 to
 care
Â
Â
Pa,ent
 rights
 and
 responsibili,es
Â
Â
Primary
 care
Â
Â
Care
 management
 and
 coordina,on
 capability
Â
Prac,ce
 paeerns
 and
 performance
 repor,ng
Â
Â
Program
 opera,ons
Â
Â
â⯠HEDIS
Â
â˘âŻ Clinical
 Quality
 Measures
Â
â˘âŻ EďŹciency/overuse/u,liza,on
Â
â˘âŻ Pa,ent
 experience
Â
16. NCQA
 Evalua,on
Â
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
â˘âŻ
ACO
 structure
 and
 opera,ons
Â
Access
 to
 needed
 providers
Â
Pa,ent-ÂâCentered
 primary
 care
Â
Care
 management
Â
Care
 coordina,on
 and
 transi,ons
Â
Pa,ent
 rights
 and
 responsibili,es
Â
Performance
 repor,ng
 and
 quality
Â
improvement
Â
17. Medicare
 Shared
 Saving
 Program
Â
(MSSP)
 Eligibility
Â
â˘âŻ Applica,ons
 accepted
 annually
Â
â⯠No,ce
 of
 Intent
 must
 be
 ďŹled
Â
â˘âŻ Summer
 2014
Â
â˘âŻ Three-Ââyear
 term
Â
â˘âŻ Applica,on
 must
 demonstrate
Â
â⯠Ongoing
 quality
 assurance
 and
 improvement
Â
â⯠Prac,ce
 of
 evidence-Ââbased
 medicine
Â
â⯠Pa,ent
 engagement
Â
â⯠Care
 coordina,on
Â
â˘âŻ Decision
 regarding
 one-Ââsided
 or
 two-Ââsided
 ACO
Â
18. One-ÂâSided
 vs.
 Two-ÂâSided
 ACO
Â
One-Ââ
Sided
Â
â˘âŻ Annual
 shared
 savings
Â
payment
Â
â˘âŻ No
 penalty
 for
Â
expenditures
 exceeding
Â
benchmark
Â
â˘âŻ First
 three
 years
 only
Â
Two-Ââ
Sided
Â
â˘âŻ Penalty
 for
 expenditures
Â
exceeding
 benchmark
Â
â˘âŻ Higher
 payment
 if
Â
expenditures
 are
 less
 than
Â
benchmark
Â