Medicare's first experiment with accountable care started with the New Year. But for the hospitals and doctors that agreed to closely manage medical care and spending for 860,000 seniors, it's too soon to tell what new investments the initiative will require, executives say.
ACO Pioneers making tentative plans
The 32 medical groups, health systems and hospitals named last month by the CMS as accountable care “Pioneers” were selected, in part, for their readiness and resources. But much of providers' planning will depend on what type of care patients need. That information is contained in data hospitals and doctors won't get until after patients are notified and given a chance to opt out, they said. Pioneer ACOs will begin to receive data this month or early in February, according to the CMS.
The CMS announced the Pioneers in the final weeks of last year and touted the effort as a money-saving push to improve patient care. Pioneers are projected to save Medicare up to $1.1 billion over five years, federal officials said. The payment model, however, is largely untested. Under accountable care, hospitals and doctors agree to meet quality and cost-control targets and receive a share of savings, if successful.
The CMS will test accountable care more broadly in the coming year under the Medicare shared savings program. In both programs, financial incentives are based on a percentage of how much providers can reduce Medicare spending compared with what it might otherwise be. However, hospitals and doctors must also meet certain quality performance targets before they can earn bonuses.
Under the shared savings program, however, providers face less potential risk or no risk at all, but will see smaller possible bonuses. The CMS envisions that program as drawing a broader range of providers perhaps less prepared for the experiment out of the gate.
Some investments, such as technology, were already under way but will be accelerated for the program, executives with Pioneer ACOs said. Others are entirely new. Irvine, Calif.-based Monarch HealthCare, for example, added a vice president of accountable care.
Dr. Jay Cohen, executive chairman of Monarch HealthCare, an independent practice association, said the new senior position was created as a result of work on commercial accountable care and preliminary preparation for Medicare's initiative. Other newly created jobs—coordinators to help patients navigate the system, a data analyst, and likely another job in information technology—will follow, he said.
Keith Pugliese, vice president of accountable care and public policy for Brown & Toland Physicians, an independent practice association in San Francisco, said prior technology investments and existing chronic disease programs would support its Medicare accountable care effort. The physician group may expand its staff to meet the need of 17,500 Medicare enrollees expected to receive care from the ACO, he said. “We're prepared,” Pugliese said.
Many decisions will be driven by data the CMS provides regarding Medicare beneficiaries assigned to each ACO, and Pioneer executives say that until that data can be analyzed, doctors and hospitals will draw on assumptions, experience with commercial accountable care and Medicare managed care to make tentative plans about where to hire people and how to invest capital.
“If we need to add, we will,” said Mike Murphy, president and CEO at Sharp HealthCare, of potential demand for more caregivers to expand programs to manage heart disease, diabetes and other chronic conditions outside the hospital. The California health system is expected to enroll 33,000 seniors under a new accountable care contract with Medicare.
Sharp, based in San Diego, will enter the new Medicare contract with some recent experience and investments that will benefit the federal initiative, Murphy said. The system already plans to invest to expand its data warehouse for two private accountable care contracts with commercial insurers Anthem and Aetna.
About 100 miles up the California coastline from Sharp, Torrance, Calif.-based HealthCare Partners Medical Group said the medical group and independent practice association plans to hire consultants to help analyze data and develop plans based on the findings. HealthCare Partners, one of the largest Pioneers with about 115,000 seniors to be enrolled under the Medicare accountable care contract, also has some experience with commercial ACO efforts that has prepared its information technology staff for the work ahead, said Dr. William Chin, executive medical director.
Chin said he expects HealthCare Partners to hire care managers as the organization “can better identify the need” using the data eventually provided by the CMS. He said it is too early to know what expenses will be required for the effort. “Until we see what is happening in our community with the data, we're just sitting on pins and needles,” Chin said. That does not mean that medical leaders have not begun to try to make early plans, he added.
Medicare offered the Pioneer organizations a few payment choices with a range of possible bonuses and penalties. The two most popular Pioneer options were one that protects providers from risk during the first year and another that would pay successful ACOs under capitation starting in the third year.
The 12 other participants chose one of three core options that vary the possible risk and potential financial gain. Eligible savings range from 50% to 75% of the amount providers save, as long as they save at least 1%.
In Wisconsin, officials with Bellin Health Systems in Green Bay and ThedaCare in Appleton chose the core option with the largest bonus and loss potential because “we are confident that we can succeed in this model,” said Dr. David Krueger, medical director for the organizations' joint accountable care organization. “We're putting ourselves at greater risk because we think we can accomplish the goals,” he said.
Atrius Health—a not-for-profit alliance of Massachusetts multispecialty medical groups, five of which operate an ACO—also selected the core option with the largest bonus and potential loss after analyzing Medicare spending data and experience with Medicare managed care, said Atrius Medical Director Dr. Rick Lopez.
Atrius Health's participation in the Pioneer program will more than double the number of Medicare enrollees that qualify for pharmacy and nurse management already used for the groups' managed-care patients. Its ACO is expected to include 25,000 Medicare patients, Lopez said. Atrius Health also provides care for 22,000 Medicaid managed-care enrollees. The ACO, though, must expand quality measures to include some, such as depression screening, that the physician groups don't measure but must report as a Pioneer participant.
Atrius officials met for a day in December to discuss managing care for high-risk and chronic disease patients, Lopez said. Atrius physicians have experience managing care, he said, but nonetheless have work to do to prepare. “We have been actively planning about what needs to be put in place as soon as possible.”
A dozen pioneer accountable care groups, including Monarch HealthCare, signed up for the option with no risk in the first year. They will be eligible for bonuses on up to half the amount that its efforts save Medicare, as long as they reduce seniors' healthcare costs by at least 2% to 2.7%, depending on the number of seniors covered. They will not, in that first year, be at risk for penalties that under other options would be imposed if cost-control efforts fail to slow Medicare enrollees' healthcare spending. The agreement differs from four other options in another key way: ACOs that share risk in that first year also qualify for financial bonuses after a much lower savings threshold is met. They can be rewarded after saving Medicare as little as 1% of what seniors might otherwise spend on healthcare.
Monarch, Cohen said, chose the option with no risk in the first year to give the doctors time for the inevitable trial and error that comes with any new experience. Monarch will enroll as many as 20,000 seniors under its Medicare accountable care contract.
Monarch has more than a year of experience working to launch a commercial accountable care contract and in May 2010 was named as a participant in an ACO pilot launched by Dartmouth College and the Brookings Institution. Monarch's executives formed the steering committee that oversaw the planning.
Even with that considerable experience with the evolving payment and delivery model, Cohen said the organization opted to limit the number of physicians to participate during the first year and gradually expand as they gained experience.
“Nobody has ever done this before,” Cohen said. “That's a big deal.”
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