acos aren't right for everyone. are they right for you?
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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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