Health care industry warming to role of keeping you healthy

Kaiser Health News reports from the Associated Press, that big players in the health industry are seeing the cost benefits of nabbing problems before they start.  That hot lunch delivered to your door? Your health insurer might pick up the tab. The cleaning crew that fixed up your apartment while you recovered from a stroke? The hospital staff helped set that up.

Some insurers are paying for rides to fitness centers and checking in with customers to help ward off loneliness. Hospital networks are hiring more workers to visit people at home and learn about their lives, not just their illnesses.

The health care system is becoming more focused on keeping patients healthy instead of waiting to treat them once they become sick or wind up in the hospital. This isn’t a new concept, but it’s growing. Insurers are expanding what they pay for to confront rising costs, realizing that a person’s health depends mostly on what happens outside a doctor’s visit.

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America's Largest Safety-Net Health System Built A High-Performing Medicare ACO

In a recent article in the Health Affairs blog,  the NYC Health + Hospitals ACO (NYCHH ACO) reduced costs by 4–12 percent annually compared to benchmark, while continually improving quality in its first four years.  It is the only ACO in New York State to achieve shared savings in all four Medicare SSP performance years. Overall costs to Medicare have been reduced by more than $31 million, generating shared savings incentive payments of nearly $14 million.

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Medicare publishes final rule on the Quality Payment Program

The Department of Health & Human Services (HHS) finalized a new payment system for Medicare clinicians that will continue to reform how the health care system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the Sustainable Growth Rate (SGR), is designed to consolidate the SGR, Meaningful Use, and the Value Modifier into a single alternative payment system.  According to the HHS press release, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country.

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CMS announces final round of application for Next Generation ACO model

The Centers for Medicare & Medicaid Services’ (CMS) Innovation Center is accepting the second and final round of applications for its Next Generation Accountable Care Organization (ACO) model, which will begin its second performance year on Jan. 1, 2017.

The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients and allows doctors and hospitals to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

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Commonwealth Fund reports Colorado medical home pilot reduced ED use and costs

According to a Commonwealth Fund study, a multipayer medical home program piloted in Colorado led to a sustained reduction in emergency department use and costs over three years, although there were no overall cost savings for practices or patients. Primary care visits also decreased. The impact on quality was mixed: cervical cancer screening rates improved, yet colon cancer screenings and hemoglobin testing for diabetes patients decreased.

The goal of Patient Centered Medical Homes (PCMH) are to deliver primary care services in a proactive, coordinated manner and improve quality of care, including patient health outcomes– particularly those with multiple or complex care needs.  In addition, the PCMH goal is to lower by reducing the need for expensive hospital stays and emergency department visits.

The Commonwealth Fund research evaluated a pilot program involving 15 PCMH practices in Colorado serving approximately 98,000 patients both prior to the program’s launch and then again at two and three years.

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CMS announces new ACO dialysis model

CMS announced the participants for the Comprehensive ESRD Care Model, a new accountable care organization model for Medicare patients with end-stage renal disease (ESRD).  The model brings together dialysis facilities, nephrologists and other providers to form ESRD Seamless Care Organizations (ESCOs) to coordinate care for ESRD beneficiaries and reduce costs. The ESCOs will be financially accountable for quality outcomes and Medicare Part A and B spending for ESRD beneficiaries, including all spending for dialysis services.

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CMS introduces New ACO Model

According to a blog post by Patrick Conway, MD, Deputy Administrator for Innovation and Quality and Chief Medical Office, Centers for Medicare and Medicaid Services (CMS), CMS is unveiling its next generation Accountable Care Organization model, which it hopes will provide an attractive alternate for providers not yet participating in the ACO program. 

How the new model works

The new model uses a combination of fee-for-service and capitation. It creates four payment systems and two risk tracks for its participants, including one with almost full risk.

According to Conway, the Next Generation ACO Model sets more predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality of care.  Key features of the new model include:

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Medicare releases 2014 ACO results

According to a Centers for Medicare & Medicaid Services (CMS) press release, Medicare Accountable Care Organizations (ACO) continue to improve the quality of care for Medicare beneficiaries while generating financial savings.   

In Medicare's detailed results, the 20 ACOs in the Pioneer ACO Model and 333 Medicare Shared Shavings Program ACOs generated more than $411 million in total savings in 2014, which includes all ACOs’ savings and losses. At the same time, 97 ACOs qualified for shared savings payments of more than $422 million by meeting quality standards and their savings threshold. The results also show that ACOs with more experience in the program tend to perform better over time.

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Use of virtual huddles support ACO care coordination; mobile devices helping improve quality and physician satisfaction

A recent article from Hospitals and Health Networks  highlights the growing use of virtual medical huddles to help coordinate care across the care team.

Communication is critical to successfully implementing new models of care to reduce costs and keep patients from making return trips to the hospital.  But communicating across care teams can be a big hurdle for accountable care organizations.

One such organization using virtual huddles is Meritage Medical Network based in Novato, Calif. The physician-led, Medicare Shared Savings ACO includes numerous physician practices and a hospital with disparate records systems, covering a 26,000 square-mile region.

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AHA expresses concern over CMS announcement to tighten ACO fraud and abuse waivers

The American Hospital Association sent a letter to the Centers for Medicare and Medicaid Services expressing concern over CMS’s announcement that it plans to narrow legal definitions regarding fraud and abuse waivers for ACOs in the future, according to Modern Healthcare.
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Federal Trade Commission releases statement on antitrust regarding ACOs

In conjunction with the Centers for Medicare and Medicaid Services final rules for Accountable Care Organizations, The Federal Trade Commission and Antitrust Division of the Department of Justice has issued their final “Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program”, according to AHA News Now.
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