Affordable Care Act: Care Coordination Initiatives
The Accountable Care Act (ACA) offers new tools and resources to help improve healthcare. In an effort to improve health, improve the quality of care, and lower costs, the ACA provides framework for Accountable Care Organizations (ACOs) and ACO programs like the Pioneer ACO Model and Advance Payment Initiative.
Pioneer Model for ACOs
Found within the Affordable Care Act (ACA), the Pioneer ACO Model is designed for healthcare organizations and providers that are already experienced in coordinating care for patients across care settings.
The model will enable these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Savings Program. It is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients.
The payment models being tested in the first two years of the Pioneer ACO Model are a shared savings payment policy with generally higher levels of shared savings and risk for Pioneer ACOs than levels currently proposed in the Medicare Shared Savings Program. In year three of the program, participating ACOs that have shown a specified level of savings over the first two years will be eligible to move a substantial portion of their payments to a population-based model. These models of payments will also be flexible to accommodate the specific organizational and market conditions in which Pioneer ACOs work.
The Pioneer ACO Model includes strong patient protection features to ensure that patients have access to and receive high-quality care. To accomplish this goal, Pioneer ACOs will be expected to improve the health and experience of care for individuals, improve the health of populations, and reduce the rate of growth in healthcare spending. Participating ACOs will be held financially accountable for the care provided to their aligned beneficiaries. In addition, CMS will publicly report the performance of Pioneer ACOs on quality metrics, including patient experience ratings, on its website.
Currently CMS has selected 32 sites to participate as Pioneer ACO Models in this program: http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf
Affordable Care Act and Pioneer ACO Model materials referenced from CMS: http://innovations.cms.gov/initiatives/ACO/Pioneer/index.html
Advance Payment Initiative
Established by the Affordable Care Act, the Innovation Center is also considering an Advance Payment Initiative for ACOs entering the Medicare Shared Savings Program to test whether pre-paying a portion of future shared savings could encourage participation in the Medicare Shared Savings Program. Early comments on the proposed Medicare Shared Savings Program rules suggest that some providers lack ready access to the capital needed to invest in infrastructure and staff for care coordination. As such, CMS is seeking comment on the idea of allowing eligible organizations participating in the Medicare Shared Savings Program to receive an advance on the shared savings they are expected to earn, in the form of a monthly payment for each aligned Medicare beneficiary. ACOs would need to provide a plan for using these funds to build care coordination capabilities, and meet other organizational criteria. Advance payments would be recouped through the ACOs’ earned shared savings.
Under the Advance Payment ACO Model, there are three types of payments:
- An upfront, fixed payment
- An upfront, variable payment
- A monthly payment of varying amount depending on the size of the ACO
Two types of organizations will qualify for the Advance Payment ACO Model:
- ACOs that do not include any inpatient facilities AND have less than $50 million in total annual revenue.
- ACOs in which the only inpatient facilities are critical-access hospitals and/or Medicare low-volume rural hospitals AND have less than $80 million in total annual revenue.
Participation must begin in April 2012 or July 2012 by an ACO to qualify for advance payments.
Affordable Care Act and Advance Payment Initiative materials referenced from CMS: http://innovations.cms.gov/initiatives/aco/advance-payment/
