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Medicare's new ACO model preps providers for insurance ventures

Hospitals and doctors have expressed a clear willingness to start their own Medicare Advantage plans. The latest iteration of Medicare's accountable care experiment paves the way for more of them to head in that direction.

That's not to say all health systems interested in managing population health will start applying for insurance licenses. Some progressive systems such as Dartmouth-Hitchcock in Lebanon, N.H., are content to pursue value-based payment models with the help of other private insurers. However, the changes to the Medicare Shared Savings Program for accountable care organizations and the launch of the Next Generation ACO model make it clear the federal government wants providers to take more financial risk in Medicare now that they have some experience under their belts.

“It's full risk and full capitation, and I think that's really where CMS wants to go,” said Dr. Bill Bithoney, a healthcare managing director at consulting firm BDO and a former hospital executive.

ACOs are a staple of the delivery reforms embedded in the Affordable Care Act. Primary-care offices, specialists, acute-care hospitals, nursing homes and other post-acute facilities are expected to work together to manage care for a set group of patients. If groups are able to lower costs, such as by preventing expensive hospital admissions, as well as achieve high quality scores, they get to reap the rewards by sharing in some of Medicare's savings.

Providers have embraced sharing savings based on good performance, known as upside risk. But they have been less sanguine about accepting downside risk, or paying penalties if certain performance thresholds aren't met. Only 1% of Shared Savings ACOs were in two-sided risk models last year. The percentage is higher for 2016, but only marginally, with about 5% of the participants accepting the risk of penalties.

“Five percent is not a big number, but it does represent some progress,” said Josh Seidman, a senior vice president at consulting firm Avalere Health. “I think it will lay groundwork for some improvements.”

The CMS built the Next Generation program in response to provider dissatisfaction with the more stringent Pioneer ACO model, but it also wanted to make accepting full risk just as palatable as the easier incentives of the Shared Savings program. The new model prospectively assigns Medicare beneficiaries to ACOs and allows waivers for things like limits on telehealth services and the rule requiring a three-day inpatient hospital stay before Medicare pays for skilled nursing.

One of the biggest differences rests on the payment side. Starting in 2017, Next Generation participants can choose capitated payment, meaning Medicare would pay the ACOs a per-member, per-month lump sum, and providers would then be responsible for any and all care that patients need.

ACOs that burn through those payments are on the hook for the additional costs. In essence, they would act like Medicare Advantage insurers—except for the important fact their Medicare beneficiaries still have traditional Medicare coverage. That means those patients have the freedom to seek care from hospitals and doctors outside the ACO.

The process for filling the Next Generation slots was competitive since it gives hospitals and doctors more tools to coordinate care for their beneficiaries. But the CMS wanted to keep the trial group small.

“This was like getting into Harvard,” said Richard Barasch, CEO of Universal American, an insurance company that has invested heavily in Medicare's ACO models. Universal American's Accountable Care Coalition of Southeast Texas was named one of the 21 Next Generation ACOs. The company “absolutely” will look at the capitation model in the second year since it already runs Medicare Advantage plans, Barasch said.

Rob Lazerow, a practice manager at the Advisory Board Co., a consulting firm that works with hospitals and doctors, said some Next Generation ACOs may form their own Medicare Advantage plan as they gain more experience. These will be provider organizations that have stronger finances, are willing to devote large capital reserves to insurance payouts and have the drive to run health plan operations.

Gaining experience with capitation as an ACO “absolutely” could push some providers to explore becoming insurers, said Seidman, who was a health technology director in the Obama administration before joining Avalere. “The question is, to what extent are ACOs destinations or stepping stones to something else?”

Provider organizations that don't have an insurance infrastructure or want to avoid the increased regulatory oversight associated with insurance may prefer to stick with accountable care contracts.

“The Next Generation model gives providers similar incentives as if they were in a Medicare Advantage plan if they choose the full-risk option,” Lazerow said. “But it lets providers focus on being population health managers rather than health plan executives.”

What's clear, though, is that provider groups that decide to start their own Medicare plans, or at least choose the capitated approach, have the chance to make money. When BDO's Bithoney was a hospital CEO within the Sisters of Providence Health System in Springfield, Mass., his team worked with Tufts Health Plan on its Medicare Advantage product. His system “curated” the care for Tufts' Medicare patients while Tufts handled the administrative end.

The end result? The system and insurer saved 12.8% of the Medicare Advantage budget for the 5,000-plus members, which would've been 4% in today's reimbursement environment, but it was still a well-received windfall.

“It was much more profitable than a (Shared Savings) ACO could be,” Bithoney said. “In Medicare Advantage, you can make more money if you're confident you can save more money.”


Bob Herman

Bob Herman covers the health insurance industry and other healthcare news. Before joining Modern Healthcare in 2014, he covered hospital finance as a reporter and editor at Becker’s Hospital Review. He has a bachelor's degree from Butler University in Indianapolis

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