ACOs Aren’t For Everybody. Are They Right For You?Kevin W. O’Neil MD, FCAP, CMDChief 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

► Only those with original Medicare can be assigned to an ACO

► Those with a Medicare Advantage/Replacement Plan (Part C), like an HMO or a PPO, cannot be assigned to an ACO.

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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. A willingness to become accountable for the quality, cost, and overall care of the Medicare beneficiaries it treats

2. Entrance into an agreement with the Secretary of Health and Human Services (HHS) to participate in the program for not less than 3 years

3. A formal legal structure that allows the entity to receive & distribute payments

4. The inclusion of primary care professionals that are sufficient for the number of Medicare beneficiaries assigned to the ACO

5. Provision to the Secretary of information regarding the professionals who participate in the ACO and implementation of quality and other reporting requirements

6. A leadership and management structure that includes clinical and administrative systems

7. Defined processes that promote evidence-based medicine and patient engagement, reporting on quality and cost measures, and care coordination

8. 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

• 85+

• Female 70%

• Multiple chronic medical conditions

• 5+ medications

• High prevalence of cognitive impairment

• 80% Medicare

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Assisted Living Landscape

• 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

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*Source: National Center for Health Statistics, 2010

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

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

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GAO Targets Assisted Living

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Medicare ACOs

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• 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

• 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 SystemU.S. Healthcare System

Tranquil GardensNursing Home

HomeCare

Acute CareFacility

Outpatient/Ambulatory

Facility

Long Term CareFacility

Many Hospitalizations are Avoidable

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Advantages of an Integrated Care Model

Source: Dobson, DaVanzo and Associates,

“Clinically Appropriate and Cost Effective

Placement,” available at

www.healthreformgps.org/wp-

content/uploads/cacep-report.pdf.

Proportion of Medicare Patients

Placed in an Avoidably High-Cost

Setting

Study Findings By Post-Acute Setting

20% of SNF patients

can be served in a home

environment

42%

30%

20%

14%

Appropriate

Setting OP Therapy HHA SNF IRF

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Why Focus On Care Transitions?

• 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.

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“BOOST”(Better Outcomes for Older Adults

Through Safe Transitions)http://www.hospitalmedicine.org

“Project RED”(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

“POLST” (or “MOLST”)(Physician (or Medical) Orders

For life Sustaining Treatment)http://www.ohsu.edu/polst

• Advance care planning

“Bridge Model”http://www.transitionalcare.org/the-bridge-model

• Social Worker coordinating Aging Resource

Center Services at hospital discharge

“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

High Quality Care

Transitions for

Older Adults &

Caregivers

INTERACT is One of Several Evidence-Based Care Transitions Interventions

Overview of QI Programs

Courtesy: Dr. Joseph Ouslander

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The Checklist

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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

INTERACT Tools

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Empowering Frontline Staff

AL Resident Retention

Revenue Lost From Turnover

5.9%

Assisted living

revenue lost to vacancy

Assisted living revenue

lost to fee concessions

National Resident Turnover Assisted Living, 2004-2012

Reasons for Resident Discharge Assisted Living, 2009

An Avoidable National Problem

Chief Medical Officer, Senior Living Organization

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Hospitalization Associated With Resident Turnover

Risk of Functional Status Decline

Following Hospitalization

(240%)Decline in global cognitive

score, comparing year

before and after

hospitalization

Percent of hospitalized

elderly patients developing

symptoms of depressed

functioning unrelated to

acute diagnosis

40.5%

6 months after

hospitalization

Without

hospitalization

5.55%

0.54%

Likelihood of Nursing Home Admission

Medicare Beneficiaries Aged 66+, 1996-2008

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Hospital Stay

$14,200

Home Care 1->6

Visits

$870

210Docs

Drugs& Tx

No Home

Support

Rehab/LTC Stay

$11,190

ER Visit

$1516

Acute Change in Condition$625

Unsustainable Traditional Model

$27,776

AL Resident

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ALF

OnsitePCP

Integrated Service Model

Practice Support

Key Components

IntegratedService Model

HHA

REHAB

NURSEEMS

Hospice

Service Array

Integrated Model – Provide vs. Arrange

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Onsite Services in Residential Care Communities

► 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

• 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

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Care Integration Will Require…

• Regulatory reform

• Greater licensure standards across states

• Investment in data infrastructure

• Electronic health records

• Quality measurement

• Innovation around delivery level interventions

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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

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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

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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 1-800-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

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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: 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-your-care/accountable-care-organizations.html

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Questions?

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