If you’ve seen one ACO…., you’ve seen more than the rest of us William F.

Report
If you’ve seen one ACO….,
you’ve seen more than the rest of us
William F. Jessee, MD, FACMPE
MGMA / ACMPE President and CEO
May 13, 2011
Copyright 2011 Medical Group Management Association. All rights reserved.
Accountable Care Organizations
Accountable Care
Organizations
Vs.
Accountable Care Organizations
Copyright 2011 Medical Group Management Association. All rights reserved.
Accountable for what?
• Safety
• Quality
• Cost-effectiveness
• Patient satisfaction
• Staff satisfaction (including physicians)
Copyright 2011 Medical Group Management Association. All rights reserved.
Accountable to whom?
• Patients
• Payers
– Private (insurers, employers)
– Public (Medicare, Medicaid)
• Public at large
Copyright 2011 Medical Group Management Association. All rights reserved.
Accountability is manifested by…
• Measures of performance (safety,
quality, cost-effectiveness,
satisfaction)
• Revenues (payments) based at least
in part on performance
Copyright 2011 Medical Group Management Association. All rights reserved.
An Accountable Care Organization (ACO) is, by definition,
a provider organization that bears some degree of
financial risk for effective performance in caring for a
population of patients. Within any ACO there may be a
mix of payment methods, and a mix of risks.
In general, higher risk payment methods can be higher
reward, but they also require higher degrees of provider
integration and care coordination.
Copyright 2011 Medical Group Management Association. All rights reserved.
Accountability and payment
Comprehensive
Care Payment
Risk
Bundled
Payment
Gain Share or
“Shared
Savings”
Fee For Service
Integration
Copyright 2011 Medical Group Management Association. All rights reserved.
Issues and concerns
• The term “ACO” has rapidly come to have different
meanings to different audiences---including CMS
• The “statutory” Medicare ACO model---set forth in the
recent proposed rule---has numerous issues:
– Modeled on Medicare demos that were only partially
successful in large, sophisticated organizations after 3 years
– Beneficiary attribution
– Requires significant new costs to the provider organizations,
but offers no up front Stark & anti-kickback waivers
– Offers VERY modest incentives
– Includes penalties that were absent in the demos
– Creates significant new data reporting burdens
Copyright 2011 Medical Group Management Association. All rights reserved.
Suggestions
• Clarify the difference between the limited Medicare
Shared Savings Program and the broader ACO
concept
• Modify the MSSP proposal to make it more attractive to
smaller organizations: less risk, lower savings
thresholds, better predictability re who the patients are,
reduced data burden
• Broaden fraud & abuse waivers to facilitate necessary
up front investments
Copyright 2011 Medical Group Management Association. All rights reserved.
Suggestions
• Medicare MUST coordinate with the private sector in
each geographic area---standard measures, standard
incentives---for both MSSP and CMMI demos
• CMMI should be aggressive in allowing providers to
accept global financial risk, AND to be accountable for
results (quality, safety, satisfaction and costeffectiveness)---but let the ACO innovate in how it pays
its providers
Copyright 2011 Medical Group Management Association. All rights reserved.

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