Pathways to Success – Dr. Miltie

ACO Announcements Add to Existing Skilled Nursing Pressures

Dr. M Telehealth — Mon, 10 Sep 2018 05:03:38 +0000

By Maggie Flynn | September 10, 2018

Value-based arrangements generate much of their savings by shifting spending away from the post-acute setting, according to recent government announcements. That ups the already-high pressure on skilled nursing facilities to lower patient length of stay while maintaining quality of care.

To cope, they’ll have to make themselves invaluable to both referral sources and payers who are part of accountable care organizations (ACOs). But SNFs will have to adjust to more than just the government changes.

“Overall, SNF behavior will be changing over the next couple of years, and it’s much broader than any changes in the ACO program,” Mike Cheek, senior vice president of reimbursement policy at the American Health Care Association (AHCA) told Skilled Nursing News. “As you know, Medicare Advantage penetration continues to increase, and that brings pressure to decrease length of stay. The Patient-Driven Payment Model (PDPM) also incentivizes shorter lengths of stay.

New ‘Pathways’ proposed

The Centers for Medicare & Medicaid Services (CMS) issued a proposal in late August to overhaul how groups of providers take on risk when they take responsibility for the total cost and quality of care of their patients. Currently under the Medicare Shared Savings Program (MSSP), ACOs have up to six years to avoid taking on risk under waivers from certain federal requirements. The “Pathways to Success” overhaul would cut the time an ACO can remain in the program without taking risk to two years.

That drive by CMS is the biggest issue for SNFs, according to Brian Ellsworth, vice president of public policy and payment transformation at the Minneapolis-based consulting firm Health Dimensions Group.

“I think over 80% of the ACOs in [the MSSP] don’t face downside risk,” he told SNN. “What we’ve seen out in the market when that’s the case is that the ACOs aren’t nearly as aggressive in terms of managing expenditures and driving change, particularly with respect to post-acute care.”

The Pioneer ACOs and the Next Generation ACOs both had to face downside risk, and many of them engaged with post-acute care to drive significant expenditure changes, Ellsworth noted. But the MSSP ACOs that faced no downside risk have not done the same, he said.

AHCA doesn’t have a count on how many SNFs are currently involved with ACOs, or how many would be involved with Pathways, Cheek said. But he agreed with Ellsworth that risk will be the most pertinent factor.

“I think it’s more of a question of how many existing ACOs, and how many potential ACOs, are willing to take on the downside risk,” Cheek said. “That’s a big jump for some of the existing ACOs to take on that sort of management of payments from CMS and … in effect, it’s functioning like a Medicare Advantage plan-lite. So I think it’s more a question of how the ACOs react, or the organizations that were considering becoming ACOs.”

How SNFs need to respond

Soon after CMS issued the Pathways proposal, it announced that the Next Generation ACO model had generated almost $62 million in savings for Medicare, in part by cutting spending in SNFs. Specifically, the ACOs reduce Medicare outlays in that setting by $16.61 million.

The Next Generation and Pioneer ACOs, as well as any in the risk tracks in the MSSP, are the most noticeable and the ones local SNFs tend to be most aware of, Ellsworth said.

“Those ACOs have done strategies like preferred networks and enhanced communication with providers, and in some cases, some attempts at clinically integrating care,” he said.

In light of both those factors and the overhaul proposal, SNFs will have to focus on how to cut lengths of stay. That’s an especially urgent task given the incentives of PDPM, the pressures from Medicare Advantage, and the various bundled payment programs from CMS, which pay for whole episodes of care and allow participating organizations to retain any savings.

“There are a number of elements that are placing pressure on shortening length of stay and so because of all those elements as well as Pathways, I think SNFs should be thinking about how to efficiently and in a manner that ensures quality, shorten length of stay overall,” Cheek stressed.

Ellsworth had similar words of advice.

“SNFs should be assessing what payers and referral sources in their market face downside risk and seek to engage those payers and providers in a discussion about their value proposition,” he said.

To do that, they’ll have to establish how they can provide high-quality, low-cost care, show good performance metrics, and engage with health systems and providers on initiatives like electronic medical records and clinical integration, he added.

Cheek also argued that SNFs should be examining clinical care to make it more efficient and more closely focused on patient characteristics. That would likely let them have a dialogue with ACOs on what the most appropriate length of stay should be.

“I’d also say thinking through how they can infuse care coordination functions into their buildings is important,” he added.

Written by Maggie Flynn

The post ACO Announcements Add to Existing Skilled Nursing Pressures appeared first on Dr. Miltie.

CMS Proposes “Pathways to Success,” an Overhaul of Medicare’s ACO Program

Dr. M Telehealth — Thu, 09 Aug 2018 05:07:48 +0000

Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would overhaul the Medicare Shared Savings Program, which is the program established by the Affordable Care Act and launched in 2012 under which the vast majority of Medicare’s Accountable Care Organizations (ACOs) operate. The redesigned program is called “Pathways to Success.”

ACOs are groups of health care providers that agree to take responsibility for the total cost and quality of care for their patients. In return, ACOs receive a portion of the savings they achieve, and CMS provides them with waivers to provide the regulatory relief needed to innovate. 10.5 million beneficiaries in Fee-for-Service Medicare (of the 38 million total Fee-for-Service beneficiaries) are in a Shared Savings Program ACO.

“President Trump has promised the American people better healthcare at a lower cost, and delivering this kind of value is a key priority for HHS,” said HHS Secretary Alex Azar. “One piece of our vision for value-based transformation is pioneering bold new payment models. Having more Accountable Care Organizations take on real risk, while offering them the flexibility they need to generate savings, is an important step forward in how Medicare pays for value.”

“After six years of experience, the time has come to put real ‘accountability’ in Accountable Care Organizations. Medicare cannot afford to support programs with weak incentives that do not deliver value,” said CMS Administrator Seema Verma. “ACOs can be an important component of a system that increases the quality of care while decreasing costs; however, most Medicare ACOs do not currently face any financial consequences when costs go up, and this has to change.”

CMS recognizes the timing issues associated with the implementation of any final policies and the need for organizations to make decisions about participation in an ACO track. To that end, CMS proposes a 6-month extension for current ACOs whose agreements expire at the end of 2018, along with a special one-time July 1, 2019 start date that will have a spring 2019 application period for the new participation options.

Pathways to Success was developed based on a comprehensive analysis of the performance of ACOs to date. Despite the program’s intent, the Shared Savings Program has shown increases in net spending for CMS and taxpayers, in part because the majority of ACOs – 460 of the 561 or 82% of all ACOs in the Shared Savings Program in 2018 – are not taking on risk for increases in costs. Data on ACO performance to date has shown that ACOs that are not at risk for cost increases end up increasing Medicare spending in aggregate. Pathways to Success is designed to move in a new direction and advance five goals: Accountability, Competition, Engagement, Integrity, and Quality. The projected financial impact of the proposal would be savings to Medicare of $2.2 billion over ten years.

Accountability and Competition

Under the current Shared Savings Program, ACOs have up to six years without taking on risk, while being granted waivers from certain federal requirements. These ACOs receive a shared savings payment from CMS when they keep costs down, but they do not have to pay taxpayers back when costs are high.

This opportunity for bonus payments if spending is low without any risk of losses if spending goes up – along with the provision of waivers – may be encouraging market consolidation. Such consolidation reduces choices for patients and can ultimately increase costs. Therefore, in response to President Trump’s Executive Order Promoting Healthcare Choice and Competition and in order to drive value, CMS proposes reducing the amount of time that an ACO can remain in the program without taking on risk down to, at most, two years.

CMS will continue to provide technical assistance to ACOs and support the sharing of best practices through collaboratives. But after six years of experience, the program must evolve to deliver value.

Beneficiary Engagement

CMS’s proposal puts the patient in the driver’s seat and provides them with the information they need to make decisions about their care. In Pathways to Success, CMS proposes to require that beneficiaries receive a notification at their first primary care visit of a performance year informing them that they are in an ACO and explaining what that means for their care. To bolster beneficiary engagement, CMS proposes to allow certain ACOs under performance-based risk to provide incentive payments to patients for taking steps to achieve good health.

Quality

As providers take on increasing accountability, CMS intends to reward them by increasing flexibility. Pathways to Success includes proposed changes which would leverage new CMS authorities under the Bipartisan Budget Act of 2018, such as allowing physicians in ACOs that take on risk to receive payment for telehealth services provided to patients regardless of the patient’s location – including at their place of residence. This new flexibility will expand access to high-quality services in a manner that is convenient for patients.

As part of the Administration’s broader MyHealthEData initiative, this proposed rule promotes interoperability and patient control of their medical data by proposing a new requirement around ACO adoption of the 2015 edition of Certified EHR Technology (CEHRT). And as part of the Administration’s broader Meaningful Measures initiative to reduce burden, the proposal aims to streamline the measures that ACOs are required to report, to ensure that all measures have a meaningful impact on patient care.

Integrity

CMS intends to ensure that ACO spending targets accurately reflect spending levels and growth rates in their local market. Therefore, Pathways to Success proposes incorporating regional spending into ACO targets earlier, starting during an ACO’s first agreement period. In addition, the proposal would authorize termination of ACOs with multiple years of poor financial performance.

For more information regarding Medicare Shared Savings Program Notice of Proposed Rulemaking (CMS-1701-P), “Accountable Care Organizations‑‑Pathways to Success,” please visit https://www.federalregister.gov/public-inspection/ and https://www.cms.gov/newsroom/fact-sheets/proposed-pathways-success-medicare-shared-savings-program.

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