ACOs Aren’t For Everybody. Are They Right For You? Kevin W. O’Neil MD, FCAP, CMD
Chief Medical Officer, Brookdale Senior Living
What is an ACO?
ACO = Accountable Care Organization
CMS: "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it. Seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. Accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the health care provided. http://youtu.be/ULy5vjcGuDc
ACO Stakeholders
Providers”: Comprised mostly of hospitals, physicians, and other healthcare professionals. May also include health departments, social security departments, safety net clinics, and home care services. Payers: The federal government, in the form of Medicare is the primary payer. Other payers include private insurances, or employer-purchased insurance. Patients: Primarily consist of Medicare beneficiaries. In larger and more integrated ACOs, the patient population may also include those who are homeless and uninsured.
Operating Model
How do ACOs work?
Healthcare providers and Hospitals
Coordinate Care Communicate with each other Partner with you in making decisions Reduce duplication of information and services through sharing electronic health information (EHI)
Source: https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.html
ACOs In Perspective
Think of it like buying a television... Samsung may contract with different manufacturers for the component parts of their televisions. But Samsung is responsible for ensuring that all the parts work together so there is a well functioning television. Similarly, an ACO will be entrusted to bring together the different component parts of care for the patient (e.g., primary care physicians, specialists, hospitals, home health care) and ensure that all work well together. A problem today is that patients are getting each part of their health care separately – they are buying individual components, not a whole TV.
How do ACOs work? (cont.) ►
Unlike Managed Care, or some insurances, ACOs CANNOT: – Tell you which health care providers to see – Change your Medicare benefits
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Only those with original Medicare can be assigned to an ACO
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Those with a Medicare Advantage/Replacement Plan (Part C), like an HMO or a PPO, cannot be assigned to an ACO.
How ACOs share information?
Using electronic health records and data from Medicare, ACOs share information about the individual’s: Medical History Medical Conditions Prescriptions Doctor visits
The privacy and security of your medical information is protected by federal law. You still have the same rights as you do today!
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How Does It Differ From HMOs?
The principle difference between HMOs and ACOs is their size
HMOs, like most insurance companies, generally have enrollees in the hundreds of thousands compared with as few as 5,000
HMOs function like insurance companies (they bear 100 percent of the risk that the premiums they charge will not be enough to cover all necessary services for their enrollees) while ACOs will bear little or no insurance risk in their first few years
Key Concepts
The key concepts for ACOs are “continuum of the care” and “quality of the care”
ACOs in the future will see incentives for providers who keep costs down and still manage to meet specific quality benchmarks, concentrating on prevention of chronic diseases and efficient disease management
Keeping the costs of hospitalizations under control and then providing quality home healthcare to patients is essential to success
Requirements For ACO Status 1.
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A willingness to become accountable for the quality, cost, and overall care of the Medicare beneficiaries it treats Entrance into an agreement with the Secretary of Health and Human Services (HHS) to participate in the program for not less than 3 years A formal legal structure that allows the entity to receive & distribute payments The inclusion of primary care professionals that are sufficient for the number of Medicare beneficiaries assigned to the ACO Provision to the Secretary of information regarding the professionals who participate in the ACO and implementation of quality and other reporting requirements A leadership and management structure that includes clinical and administrative systems Defined processes that promote evidence-based medicine and patient engagement, reporting on quality and cost measures, and care coordination Demonstration that the organization meets patient-centered criteria
What Does This Mean For You?
http://youtu.be/Xlq2XJ6J76g
Doctors will want to refer patients to hospitals and specialists within the ACO network, however patients will still be free to see doctors of their choice outside the network
Because ACOs will be under pressure to provide high quality care in order to receive financial benefits, patients should ultimately receive better care
Why Should Assisted Living Providers Care About ACOs
Courtesy: Advisory Board Company
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The Typical Resident Then “Years ago, the assisted living resident was Miss Daisy -- lucid and opinionated, didn’t need extensive nursing or personal care, just transportation, light housekeeping and meals, and the attention of the courtly Morgan Freeman.”
H/T Sheryl Zimmerman, PhD
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Typical Assisted Living Resident Today
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85+ Female 70% Multiple chronic medical conditions 5+ medications High prevalence of cognitive impairment 80% Medicare
Assisted Living Landscape •
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Fastest growing segment of elder care • Over 31,000 ALFs • 971,900 beds Acuity level has increased* • 86% need assistance with taking meds • 72% with bathing • 57% with dressing • 41% with toileting • 36% with transferring • 23% with eating
*Source: National Center for Health Statistics, 2010
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Rising Acuity
Using a Walker
Heart Disease
Diabetes
Using a Wheelchair
2001
30%
28%
13%
15%
2010
45%
34%
17%
23%
Source: NCAL National Survey of Residential Care Facilities
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“The patient population is getting older so to not have a strategy to address that would be shortsighted. I definitely think both assisted living facilities and acute care providers are on the hook. To not take that responsibility to some degree and work with partners is a big mistake.� – Kendall Johnson, Senior Consultant, Strategic Partnerships and Business Development, Allina Health ACO
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Key Takeaways
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Assisted living (AL) residents have intensive and complex care needs AL residents use lots of Medicare services ALs have some clinical “infrastructure” but generally not invested in the coordination of health and LTC services Lots of care coordination efforts under the Accountable Care Act directed at community and nursing home LTC populations—focus is expanding to “rising risk” population in AL
GAO Targets Assisted Living
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Medicare ACOs
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Many Hospitalizations are Avoidable As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate ► Saliba et al, J Amer Geriatr Soc 48:154-163, 2000 •
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In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnoses” Grabowski et al, Health Affairs 26: 1753- 1761, 2007 Over $25 Billion spent annually on preventable hospitalizations Agency for Healthcare Research and Quality. Preventable Hospitalizations: a window into primary and preventive care, 2000. http://archive.ahrq.gov/data/hcup/factbk5/factbk5.pdf.
U.S. Healthcare System
Acute Care Facility Home Care
Outpatient/ Ambulatory Facility Tranquil Gardens Nursing Home
Long Term Care Facility
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Advantages of an Integrated Care Model Proportion of Medicare Patients Placed in an Avoidably High-Cost Setting Study Findings By Post-Acute Setting 42%
20% of SNF patients can be served in a home environment
30%
20% 14%
Source: Dobson, DaVanzo and Associates, “Clinically Appropriate and Cost Effective Placement,� available at www.healthreformgps.org/wpcontent/uploads/cacep-report.pdf. Appropriate Setting
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OP Therapy
HHA
SNF
IRF
Why Focus On Care Transitions? • •
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20% of Medicare beneficiaries readmitted within 30 days Negative physical, emotional, psychological impact Costs Medicare billions of dollars $26 billion annually $17.5 billion on in-patient spending Avoidable hospitalizations/readmissions a key strategy 25-42% of readmissions are avoidable Source: Jordan Rau. Medicare Revises Hospitals’ Readmissions Penalties, Kaiser Health News. Oct. 2, 2012. Long-Term Quality Alliance. Improving Care Transitions: how quality improvement organizations and innovative communities can work together to reduce hospitalizations among at-risk populations. June 2012.
Overview of QI Programs INTERACT is One of Several Evidence-Based Care Transitions Interventions “BOOST” (Better Outcomes for Older Adults Through Safe Transitions)
“Bridge Model”
http://www.hospitalmedicine.org
http://www.transitionalcare.org/the-bridge-model
“Project RED”
• Social Worker coordinating Aging Resource Center Services at hospital discharge
(Re-Engineered Discharge) https://www.bu.edu/fammed/projectred
• Enhanced hospital discharge planning
“Care Transition Program” http://www.caretransitions.org
• Transition coach • Trained volunteers • Empowered patients and caregivers
High Quality Care Transitions for
Older Adults & Caregivers
“POLST” (or “MOLST”) (Physician (or Medical) Orders For life Sustaining Treatment) http://www.ohsu.edu/polst
• Advance care planning
Courtesy: Dr. Joseph Ouslander
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“Transitional Care Model” http://www.transitionalcare.info/index.html
• APN coordinates care during and after discharge • Home, SNF, and clinic visits
“INTERACT” (Interventions to Reduce Acute Care Transfers) http://interact2.net
• Communication Tools, Care Paths, Advance Care Planning Tools, and QI tools for nursing homes and ALFs
The Checklist
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INTERACT Tools
This Transfer Checklist can be printed or taped onto an envelope, and is meant to compliment the Transfer Form by indicating which documents are included with the Form
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Empowering Frontline Staff
AL Resident Retention National Resident Turnover Assisted Living, 2004-2012
Revenue Lost From Turnover
Reasons for Resident Discharge Assisted Living, 2009
An Avoidable National Problem
Assisted living revenue lost to vacancy
5.9%
Assisted living revenue lost to fee concessions Chief Medical Officer, Senior Living Organization
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Hospitalization Associated With Resident Turnover Likelihood of Nursing Home Admission Medicare Beneficiaries Aged 66+, 1996-2008 5.55%
(240%)
Decline in global cognitive score, comparing year before and after hospitalization
Risk of Functional Status Decline Following Hospitalization
40.5%
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Percent of hospitalized elderly patients developing symptoms of depressed functioning unrelated to acute diagnosis
0.54%
6 months after hospitalization
Without hospitalization
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Unsustainable Traditional Model Acute Change in Condition
$625
AL Resident
210 Docs
No Home Support
ER Visit
$1516
Drugs & Tx
$27,776 Home Care
Hospital Stay
1->6 Visits
$870
Rehab/ LTC Stay
$11,190
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$14,200
Integrated Model – Provide vs. Arrange
Key Components
Service Array
ALF HHA
Onsite PCP
Integrated Service Model
Hospice Integrated Service Model
EMS Practice Support 33
REHAB
NURSE
Onsite Services in Residential Care Communities
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89% provide physical, occupational, or speech therapy 76% provide skilled nursing services 89% provide disease-specific programs for residents with dementia 89% provide hospice care
Source: 2012 Centers for Disease Control and National Center for Health Statistics study
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Assisted Living & Triple Aim
Hospitals can form effective partnerships with ALFs to manage this population by: 1. Assessing ALF capabilities and alignment with hospital goals 2. Establishing care coordination programs 3. Building coalitions of quality PAC and LTC providers 4. Measuring and maintaining the partnership
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Assisted Living: The Next Frontier
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AMDA---The Society for Post-Acute and Long-Term Care Medicine Argentum National Center for Assisted Living (NCAL) Center for Excellence in Assisted Living (CEAL) Leading Age
Care Integration Will Require…
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Regulatory reform Greater licensure standards across states Investment in data infrastructure • •
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Electronic health records Quality measurement
Innovation around delivery level interventions
Key Takeaways
Most of your residents are Medicare beneficiaries. Most Medicare beneficiaries will be enrollees in an ACO, a Medicare Advantage Plan, or some value-based system. Healthcare providers (hospitals, physicians, and care managers) will be intensely focused on improving quality and reducing cost. Healthcare providers will be focused on building collaborations with quality post-acute and long-term care providers. Referral networks will be getting more narrow. Providers will influence patient and family decisions about the most appropriate care setting. There will be winners and lots of losers. Assisted living can be part of the solution in achieving the Triple Aim
Frequently Asked Questions
“If I participate in an ACO, can I still see whichever doctor/healthcare provider I want?” Yes! Even if your doctor/healthcare provider participates in an ACO, you can see any health care provider who accepts Medicare. Nobody – Not your doctor, not your hospital, can tell you who you have to see. Source: CMS https://www.medicare.gov/Pubs/pdf/11588.pdf 39
Frequently Asked Questions
“How do I know if my healthcare provider is in an ACO?” You will be notified, either by letter, by sign, or in conversation, that your doctor/healthcare provider chooses to participate in an ACO. If you aren’t sure, you can ask him/her. Source: CMS https://www.medicare.gov/Pubs/pdf/11588.pdf 40
Frequently Asked Questions
“What can I expect if my healthcare provider is in an ACO?” Your Medicare benefits won’t be limited, you still have the right to choose any hospital or doctor that accepts Medicare. Some ACOs hire people to check on your care – they may call you after an appointment or a procedure to make sure your questions or concerns are answered and that you get the right care. You may find you have less paperwork to fill out and that the provides know more about your health, since ACOs share information about you. Source: CMS https://www.medicare.gov/Pubs/pdf/11588.pdf
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Frequently Asked Questions
“What if my healthcare provider is participating in an ACO and I don’t want my health information shared?” Your privacy is very important. You can tell Medicare not to give your doctor’s ACO information by calling 1800-MEDICARE (1-800-486-2048). Unless you take this step, your medical information will be shared automatically with your doctor’s ACO. Source: CMS https://www.medicare.gov/Pubs/pdf/11588.pdf 42
Resources
For more information contact . . . Centers for Medicare and Medicaid: Website: www.Medicare.gov or
Phone: 1- 800 – MEDICARE 1- 800 – 633 - 4227
Online Resources:
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Accountable Care Organizations & You: Frequently Asked Questions (FAQs) for People with Medicare CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/. Medicare.gov/manage-your-health/coordinating-yourcare/accountable-care-organizations.html
Questions?
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