Accountable Care Organizations (ACOs)

Accountable Care Organizations (ACOs) / en Fri, 25 Apr 2025 20:16:37 -0500 Thu, 27 Mar 25 13:46:53 -0500 AHA Comments on PTAC Total Cost of Care Model Proposal /lettercomment/2025-03-27-aha-comments-ptac-total-cost-care-model-proposal March 27, 2025Terry Mills Jr., M.D., M.M.M, Co-chair Soujanya Pulluru, M.D., Co-chair ATTN: Physician-Focused Payment Model Technical Advisory Committee&nbsp; Assistant Secretary for Planning and Evaluation, Room 415F U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, D.C. 20201RE: Request for Input Reducing Barriers to Participation in Population-Based Total Cost of Care Models and Supporting Primary and Specialty Care TransformationDear Co-chairs Mills and Pulluru,&nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to share our comments regarding the Physician‐Focused Payment Model Technical Advisory Committee’s (PTAC) request for input on barriers to transitioning to population-based total cost-of-care (PB-TCOC) and primary and specialty care models.In particular, we urge the PTAC to:<ul><li>Adopt common principles that will support the implementation of PB-TCOC, primary and specialty care models.</li><li>Recommend removal of high/low revenue thresholds, which inappropriately prevent certain providers from entering primary and specialty care models.</li><li>Recommend extension of the advanced alternative payment model (APM) incentive payments.</li><li>Recommend more sustainable reimbursement to support the transition to value better.</li></ul>Our detailed comments on these issues follow.<h2>COMMON PRINCIPLES FOR PB-TCOC, PRIMARY CARE AND SPECIALTY MODELS</h2>Our members support the U.S. health care system moving toward the provision of more outcomes-based, coordinated care, and we continue to redesign delivery systems to increase value and better serve patients. Over the last 15 years, our hospital and health system members participated in a variety of APMs, including primary care and specialty care models as well as total cost-of-care models.While the movement to value holds tremendous promise, the transition has been slower than anticipated and more needs to be done to drive long-term system transformation.There are principles that we believe should guide the design of such APMs to make participation more attractive for potential participants, including hospitals, health systems and independent providers. These include:<ul><li>Appropriate On-ramp and Glidepath to Risk. Model participants should have an adequate on-ramp and glidepath to transition to risk. They must have adequate time to implement care delivery changes (e.g., integrating new staff, changing clinical workflows, implementing new analytics tools) and review data prior to initiating the program.</li><li>Adequate Risk Adjustment. Models should include adequate risk adjustment methodologies to account for chronic risk factors and clinical complexity. This will ensure models do not inappropriately penalize participants for treating the sickest, most complicated and underserved patients.</li><li>Voluntary Participation and Flexible Design. Model designs should be flexible, incorporating features such as voluntary participation and options for participants to leave models.</li><li>Balanced Risk Versus Reward. Models should balance risk versus reward in a way that encourages providers to take on additional risk but does not penalize those who need additional time and experience before they are able to do so. A glidepath approach should be implemented, gradually migrating from upside-only to downside risk.</li><li>Guardrails to Ensure Hospitals Do Not Compete Against Their Own Best Performance. Models should provide guardrails to ensure that participants are not penalized over time when they achieve optimal cost savings and outcomes performance. Participants must have incentives to remain in models for the long term.</li><li>Resources to Support Initial Investment. Upfront investment incentives should be provided to support organizations in the transition to value-based payment. To be successful in such models, hospitals, health systems and provider groups must, for example, invest in additional staffing and infrastructure to support care delivery redesign and outcomes tracking.</li><li>Transparency. Models’ methodologies, data and design elements should be transparently shared with all potential participants. Proposed changes should be vetted with stakeholders.</li><li>Adequate Model Duration. Models should be long enough in duration to truly support care delivery transformation and assess the impact on outcomes. Historically, models have been too short and/or have had multiple, significant design changes even within the designated duration, making it difficult for participants to self-evaluate and change course when necessary.</li><li>Timely Availability of Data.&nbsp;Model participants should have readily available, timely access to data about their patient populations. Ideally, the Centers for Medicare &amp; Medicaid Services (CMS) would dedicate staff and technology to helping provide program participants with more complete data as close to real-time as possible.</li><li>Waivers to Address Barriers to Clinical Integration and Care Coordination. Models must include waivers to Medicare program regulations that inhibit care coordination and work against participants’ efforts to ensure that care is provided in the right place at the right time.</li></ul>We urge the PTAC to adopt these core principles for future APM model design.<h2>REMOVING PROBLEMATIC LOW-REVENUE THRESHOLDS AS CRITERIA FOR APM PARTICIPATION AND INVESTMENT PAYMENTS</h2>As mentioned above, hospitals and health systems are critical stakeholders in the journey to value. However, certain policies have hampered their ability to participate in certain models. For example, CMS has leveraged captured revenue to distinguish Accountable Care Organizations (ACOs) as “low-revenue” or “high-revenue,” and by proxy, to identify ACOs as either physician-led (low-revenue) or hospital-led (high-revenue). The agency has then limited participation in certain APMs or qualification for advanced investment payments (AIPs) to only physician-led or low-revenue ACOs. It has based this policy on the faulty assumption that low-revenue ACOs perform better than high-revenue ACOs. However, research shows there is no significant difference in performance between high- and low-revenue ACOs.1Furthermore, high-revenue ACOs often have more clinically complex, higher-cost patients attributed to their model. In addition, limiting eligibility for AIPs to only low-revenue ACOs inappropriately penalizes high-revenue ACOs, many of which are actually small organizations that critically need these resources for infrastructure investment to transition to APMs. For example, analysis suggests that critical access hospitals, federally qualified health centers and rural health centers are predominantly classified as high-revenue and therefore ineligible for AIPs. This partially explains the disparity in APM adoption in rural and underserved areas, which the PTAC has previously highlighted. We, therefore, urge PTAC to recommend the removal of these problematic high- and low-revenue thresholds that inappropriately preclude certain ACOs from obtaining necessary resources for infrastructure investment.<h2>EXTENSION OF ADVANCED APM INCENTIVE PAYMENTS</h2>The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided incentive payments of 5% for providers participating in advanced APMs. These payments were designed to assist with the provision of non-fee-for-service programs like meal delivery programs, transportation services, digital tools and care coordinators that promote population health. However, MACRA statute only provided the advanced APM bonuses through the calendar year (CY) 2024 payment period. Congress has passed single-year extensions (although at lower rates) through the CY 2026 payment period. These incentive payments provide crucial resources for providers considering the transition to PB-TCOC, primary and specialty care APMs. As such, we urge PTAC to work with CMS to urge Congress to extend these incentive payments, which will better support providers transitioning to primary, specialty and total cost of care models.<h2>PHYSICIAN ACQUISITION AND PB-TCOC, PRIMARY AND SPECIALTY CARE MODELS</h2>Some presenters in the March PTAC meeting cited the acquisition of physician practices as a barrier to APM competitiveness. However, this discussion did not fully address the situation. Specifically, much like hospitals and health systems, physicians across the country face increased costs, inadequate reimbursements and administrative burdens from public and private insurer practices. These factors create major barriers to operating an independent practice. Furthermore, the transition to value-based programs often requires infrastructure investment for electronic health records, quality reporting, analytics and support staff, which many practices may not have the economies of scale to support. As a result, physicians are increasingly looking for alternative practice settings that will provide financial security so they can focus more on clinical care and less on managing their own practice.&nbsp;While a disproportionate amount of attention has been placed on hospitals’ acquisition of physician practices, the reality is that large commercial insurers have collectively invested billions in physician practice acquisitions. Based on an AHA analysis of Levin Associates data, private equity, physician groups and health insurers have acquired the vast majority of physician practices during the last five years.2 Comparatively, hospitals rank relatively low in the acquisition of physician practices. In fact, private equity-backed startups have acquired 65% of physician practices from 2019 to 2023, and insurers have acquired 14% of practices in that same timeframe. This is compared to hospitals and health systems that have only acquired 6% of physician practices.&nbsp;Therefore, we urge PTAC to recommend policies, such as more sustainable reimbursement aligned with inflation. Doing so will better support all providers’ abilities to transition to value-based care.&nbsp;We thank you for your consideration of our comments. Please contact me if you have questions, or feel free to have a member of your team contact Jennifer Holloman, AHA’s senior associate director of payment policy, at <a href="mailto:jholloman@aha.org" target="_blank">jholloman@aha.org</a>.&nbsp;Sincerely,&nbsp;/s/&nbsp;Ashley B. Thompson&nbsp; Senior Vice President&nbsp; Public Policy Analysis and Development__________1 <a class="ck-anchor" href="https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models" target="_blank" id="https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models">https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models</a>2 <a href="/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf" target="_blank">/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf</a> Thu, 27 Mar 2025 13:46:53 -0500 Accountable Care Organizations (ACOs) CMS announces increase in accountable care relationships /news/headline/2025-01-15-cms-announces-increase-accountable-care-relationships <div>The Centers for Medicare &amp; Medicaid Services <a href="https://www.cms.gov/newsroom/fact-sheets/cms-moves-closer-accountable-care-goals-2025-aco-initiatives" target="_blank">announced</a> Jan. 15 that 53.4% of people with Traditional Medicare are in an accountable care relationship with a provider, a 4.3% increase from last year. The agency said it is the largest increase since it began tracking accountable care relationships.&nbsp;</div><div>For 2025, CMS approved 228 applications for the Medicare Shared Savings Program, bringing the total number of accountable care organizations participating in MSSP to 476. Approved applicants included 55 new ACOs and 173 renewing or reentering ACOs, the most in the program's history.&nbsp;&nbsp;</div><div>CMS said there was also a 16% increase from last year in federally qualified health centers, rural health clinics and critical access hospitals participating in the MSSP. In addition, 103 ACOs are continuing participation in CMS' ACO Realizing Equity, Access, and Community Health Model, and 78 kidney contracting entities and 15 CMS Kidney Care First Practices are continuing participation in the Kidney Care Choices Model.&nbsp;&nbsp; &nbsp; In other ACO news, the CMS Innovation Center Jan. 1 launched the ACO Primary Care Flex Model with 24 ACOs participating jointly in the MSSP. The ACO PC Flex Model provides a one-time advanced shared savings payment, monthly prospective primary care payments and incentives to support team-based care approaches to medical and social needs.&nbsp;</div> Wed, 15 Jan 2025 15:32:58 -0600 Accountable Care Organizations (ACOs) AHA Value Initiative Members in Action: Illinois Rural Community Care Organization – Princeton, IL /case-studies/2024-11-13-aha-value-initiative-members-action-illinois-rural-community-care-organization-princeton-il Wed, 13 Nov 2024 09:44:25 -0600 Accountable Care Organizations (ACOs) CMS issues final rule on ACO significant, anomalous and highly suspect billing /news/headline/2024-09-25-cms-issues-final-rule-aco-significant-anomalous-and-highly-suspect-billing The Centers for Medicare &amp; Medicaid Services Sept. 24 issued a <a href="https://www.federalregister.gov/public-inspection/2024-22054/medicare-program-mitigating-the-impact-of-significant-anomalous-and-highly-suspect-billing-activity">final rule</a> that would carve out significant, anomalous, and highly suspect (SAHS) billing from Medicare Shared Savings Program financial calculations for calendar year 2023. The final rule is part of a larger CMS strategy to address SAHS billing activity within Accountable Care Organizations’ reconciliation. Specifically, the agency also addressed this issue in the CY 2025 physician fee schedule proposed rule. The rule's changes become effective Oct. 15. Wed, 25 Sep 2024 16:10:24 -0500 Accountable Care Organizations (ACOs) CMS Issues ACO Significant, Anomalous and Highly Suspect Billing Final Rule <div class="container"><div class="row"><div class="col-md-8">The Centers for Medicare &amp; Medicaid Services (CMS) Sept. 24 issued a&nbsp;<a href="https://public-inspection.federalregister.gov/2024-22054.pdf">final rule</a> that would carve out significant, anomalous and highly suspect (SAHS) billing from Medicare Shared Savings Program (MSSP) financial calculations for calendar year (CY) 2023. This final rule is part of a larger strategy to address SAHS billing activity within accountable care organizations (ACOs) reconciliation. Specifically, the agency also addressed this issue for CY 2024 and beyond in the CY 2025 physician fee schedule proposed rule, on which the AHA&nbsp;<a href="/lettercomment/2024-09-09-aha-comments-cms-physician-fee-schedule-cy-2025-proposed-rule" target="_blank">commented</a>. This rule’s changes are effective Oct. 15.<div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2>The rule:<ul><li>Finalizes two urinary catheter codes involved in SAHS billing activity for CY 2023.</li><li>Adjusts ACOs’ performance year and benchmark year calculations for CY 2023 to account for this activity, including when CY 2023 is the performance year and when it is used to establish benchmarks for 2024, 2025 and 2026.</li><li>Excludes CY 2023 amounts from factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025.</li></ul></div></div><h2>AHA Take</h2>The AHA applauds CMS for recognizing the significant impact that anomalous catheter spending would have on ACO participants and for taking action to carve out these expenditures from ACO financial calculations. Indeed, the recent catheter billing issue increased some ACOs’ total spending by as much as 2%. As such, in many cases, the inclusion of this spending would have led to a loss of shared savings. We are pleased that the agency listened to the&nbsp;<a href="/lettercomment/2024-04-30-letter-cms-administrator-brooks-lasure-higher-spending-two-catheter-codes-and-impact-acos" target="_blank" title="Recommendations from AHA and Others">recommendations</a> from&nbsp;AHA and others to hold ACOs harmless for&nbsp;such spending beyond their control.While this is a significant step to mitigate the impact of anomalous spending for CY 2023, the 2023 catheter spending is not the first, and unfortunately likely not the last, instance of suspected fraudulent billing. We are encouraged that this is part of a broader strategy to mitigate anomalous spending and will continue to work with the agency to develop future policies to address this issue.&nbsp;Highlights of the SAHS final rule follow.<h2>Identifying Codes Displaying SAHS Billing Activity in CY 2023</h2>The agency finalized that a health care common procedure coding system (HCPCS) or current procedural terminology (CPT) code exhibits SAHS billing activity when there is a significant increase in claims, either in volume or dollars, with national or regional impact, that represents a deviation from historical utilization trends that is unexpected and is not clearly attributable to reasonably explained changes in policy or the supply or demand for covered items or services. CMS determined that two HCPCS codes displayed SAHS billing activity in CY 2023:&nbsp;<ul><li>A4352 (Intermittent Urinary Catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.) each)</li><li>A4353 (Intermittent Urinary Catheter with insertion supplies)</li></ul>Both HCPCS codes were billed at significantly higher rates in CY 2023 compared to 2022 (an increase of 163% for A4352 and over 5,000% for A4353), but CMS could not determine a clear justification for these increases. The agency also analyzed HCPCS code A4351 but determined that it did not constitute SAHS billing activity, as it increased only 16% from CY 2022 to CY 2023. Additionally, the agency reviewed skin substitute codes and determined billing activity increases were explained by deviations in local coverage determinations across Medicare Administrative Contractors.<h2>Removing Payment Amounts from Financial Calculations</h2>CMS will exclude all Medicare Parts A and B payment amounts for selected catheter HCPCS codes from expenditure and revenue calculations for CY 2023. This includes when CY 2023 is the performance year and CY 2023 is a benchmark year for ACOs in agreement periods beginning on Jan. 1, 2024, Jan. 1, 2025, and Jan. 1, 2026. Amounts also will be excluded from calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025.After receiving comments, the agency considered whether amounts also should be removed for CY 2022 and CY 2024. For performance years prior to CY 2023, the agency determined that financial reconciliation already has been completed, and therefore, the policies applied in the SAHS billing rule would not address retrospective billing increases. For CY 2024 and beyond, the agency proposed changes in the CY 2025 physician fee schedule that should be finalized around Nov. 1.CMS also received comments requesting the application of guardrails for organizations that may, for example, have shared savings decremented by removing SAHS catheter billing. The agency determined that it would not apply guardrails for adjustments to financial calculations.Finally, the agency considered comments regarding making similar adjustments for catheter codes in other programs like the ACO Realizing Equity, Access, and Community Health (ACO REACH), Bundled Payments for Care Improvement &nbsp;Advanced, and Comprehensive Care for Joint Replacement models. However, it determined that this would be beyond the scope of this rule. CMS states that the Center for Medicare and Medicaid Innovation assessed the effects of SAHS billing on each model and made determinations of whether actions were necessary on a model-by-model basis.<h2>Further Questions</h2>If you have further questions regarding the SAHS billing final rule, please contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>.</div><div class="col-md-4"><a href="/system/files/media/file/2024/09/cms-issues-aco-significant-anomalous-and-highly-suspect-billing-final-rule-bulletin-9-25-2024-f.pdf"><img src="/sites/default/files/inline-images/cover-cms-issues-aco-significant-anomalous-and-highly-suspect-billing-final-rule-bulletin-9-25-2024-f-2.pdf_.png" data-entity-uuid data-entity-type="file" width="640" height="834"></a></div></div></div> Wed, 25 Sep 2024 15:33:26 -0500 Accountable Care Organizations (ACOs) AHA Value Initiative Members in Action Case Study: Illinois Rural Community Care Organization – Princeton, IL /aha-value-initiative-members-action-illinois-rural-community-care-organization-princeton-il <div class="row"><div class="col-md-8">Illinois Rural Community Care Organization builds the structure necessary for rural providers to be successful ACOs. Click <a href="/system/files/2018-03/value-initiative-illinois-rural-community-care.pdf" target="_blank">here</a> to learn more.</div><div class="col-md-4"><a class="btn btn-wide btn-primary" href="/system/files/2018-03/value-initiative-illinois-rural-community-care.pdf">Download Case Study</a></div></div> Tue, 13 Aug 2024 16:45:56 -0500 Accountable Care Organizations (ACOs) AHA podcast discusses the benefits of joining an accountable care organization /news/headline/2024-06-21-aha-podcast-discusses-benefits-joining-accountable-care-organization Health care pressures are often magnified for rural caregivers, yet some are developing unique solutions for these turbulent times. Mary Mannix, CEO and president of Augusta Health, discusses the impact that cross-training has had on high-quality patient care in their community, and how the transition to an accountable care organization ensures patients are getting the right care at the right time. <a href="/advancing-health-podcast/2024-06-21-benefits-joining-accountable-care-organization-aco-augusta-health">LISTEN NOW</a> &nbsp; Fri, 21 Jun 2024 16:04:12 -0500 Accountable Care Organizations (ACOs) The Benefits of Joining an Accountable Care Organization (ACO) with Augusta Health /advancing-health-podcast/2024-06-21-benefits-joining-accountable-care-organization-aco-augusta-health Health care pressures are often magnified for rural caregivers, yet some are developing unique solutions for these turbulent times. In this conversation, Mary Mannix, CEO and president of Augusta Health, discusses the impact that cross-training has had on high-quality patient care in their community, and how the transition to an Accountable Care Organization (ACO) ensures patients are getting the right care at the right time.<hr>&nbsp;<div></div>&nbsp;<div class="raw-html-embed"><details class="transcript"><summary> <h2 title="Click here to open/close the transcript.">View Transcript &nbsp;</h2> </summary> 00;00;00;21 - 00;00;31;26 Tom Haederle All of the challenges facing larger hospitals and health systems - workforce issues, reimbursement rates that don't meet the cost of care, patient populations impacted by the social determinants of health, and many others, are magnified for rural caregivers. Yet in facing these realities, some rural hospitals and health systems are doing more than coping. They are thriving. 00;00;31;29 - 00;01;05;23 Tom Haederle Welcome to Advancing Health, a podcast from the �� Association. I'm Tom Haederle with AHA communications. After years of smooth functioning, the pandemic hit Augusta Health hard. The Virginia based rural health system started for the first time to experience high rates of burnout and turnover. In this podcast, we hear how Augusta responded to keep delivering the care its patients deserved by including lots of cross-training across multi-discipline care teams, strengthening the role of case managers, and most importantly, transitioned to an accountable care organization. 00;01;05;25 - 00;01;11;09 Tom Haederle Augusta's example shows how rural independent providers can be successful. 00;01;11;11 - 00;01;39;12 Michelle Hood Good day. I'm Michelle Hood, I'm the executive vice president and chief operating officer of the �� Association. And joining me today is Mary Mannix, president and CEO of Augusta Health, based in Fisherville, Virginia, and a past board member of the AHA Board of Trustees. We are here to discuss the future of rural hospitals and health systems. But first, let us share our rural credentials, if you will. 00;01;39;15 - 00;02;07;01 Michelle Hood Certainly, nobody disputes that Maine is a rural state. And as the former president and CEO of Northern Light Health, previously known as Eastern Maine Health Care in Brewer, Maine, I worked with and on behalf of several very rural hospitals, including critical access hospitals, that were members of our system. I also had the privilege of leading the Montana/Wyoming Division of the sisters of Charity of Leavenworth Health System for seven years, 00;02;07;08 - 00;02;22;26 Michelle Hood certainly, frontier medicine. Likewise, no one disputes that Virginia is a rural state, but your experience in rural health care goes back to your years in Pennsylvania. So, Mary, please share a bit of that experience with us. 00;02;22;29 - 00;02;46;29 Mary Mannix Well, yeah. Thank you Michelle. So I completed my graduate work in health care administration and have a master's in nursing and an MBA, and then did a two year postgraduate fellowship at the Guthrie Clinic and ended up staying for another 17 years. The Guthrie Clinic is kind of a hub and spoke concept. It serves two states, primarily New York and Pennsylvania. 00;02;47;01 - 00;03;23;06 Mary Mannix It has its hub located in mid-central northern tier of Pennsylvania, and then a very distributed network of rural clinics throughout the bi-state area. From there, I was then recruited to Virginia, to the Shenandoah Valley, and as you mentioned, in Fishersville, Virginia. And Augusta Health is more of a community focused, less of a hub and spoke, more of a community focused health care organization that does have a far reach throughout many rural communities in Virginia, going north all the way up to Rockingham County, south all the way down to Lexington, and then Bath and Highland. 00;03;23;09 - 00;03;34;05 Mary Mannix And of course, Augusta County is a very large area as well as the western side of Albemarle. And then Nelson County. So that's a population of about 340,000 people. 00;03;34;08 - 00;03;58;03 Michelle Hood Well, you can hear from our descriptions of at least some of our experiences in health care that rural is near and dear to us. And our commitment to those providing care to those living in rural America is steadfast. Mary, when I ask health care executives, regardless of where it is that they're currently working, what is it that keeps them awake at night? 00;03;58;05 - 00;04;13;21 Michelle Hood Hospitals and health systems still call out workforce as a critical challenge. One of the most of the critical challenges. So tell us about your workforce vulnerabilities at Augusta Health and how you are responding. 00;04;13;24 - 00;04;41;22 Mary Mannix So, you know, we were working on this workforce challenge obviously long before the public health emergency. And then everything just became accelerated with the public health emergency. At Augusta Health we were fortunate we had a very stable workforce. Even when the pandemic started on that fateful day of Friday the 13th, March 20th, and we were able to retain stability in our workforce, we didn't have any reductions in workforce. 00;04;41;23 - 00;05;08;06 Mary Mannix We did a lot of communication, we did a lot of partnership. And as we were waiting for the surge in our community, we did a lot of cross-training across multidisciplinary teams to prepare, and that served us very well. Our team members were appreciative. They loved how proactively we communicated. If we didn't know the answer to something we said we didn't know, but we'll get back to you and we worked together in a very strong sense of teamwork and spirit. 00;05;08;09 - 00;05;35;02 Mary Mannix But that third to fourth quarter of I think it was 2021 when Delta morphed into Omicron. We didn't catch a break. And that's when you really started to see some burnout, some exhaustion. And that's what Augusta Health when our turnover really began to spike. And that is when we started to become overly reliant on contract labor to be able to, you know, sustain our mission and serve our community. 00;05;35;04 - 00;06;04;14 Mary Mannix The areas that have been most challenging have been in nursing, some key areas of physician practice. We have a 260 multi-specialty physician group practice from primary care all the way through various subspecialties. We started to see a little bit of turnover there, even in areas like lab and radiology. Even in mammography, we began to see turnover, a very new phenomenon for us, and one that made us, as I said, very dependent on contract labor. 00;06;04;16 - 00;06;21;23 Michelle Hood Yeah. So I think, you know, we are still seeing that. And I think the workforce challenges that we have within our field are going to continue. You add on the demographic shifts and the aging of the population and less workforce and more choices for that workforce. And I think we've got challenges for the years ahead. 00;06;21;23 - 00;06;23;03 Mary Mannix Yeah, definitely. 00;06;23;03 - 00;06;47;19 Michelle Hood Look forward to working with you further on those. Let me shift gears a little bit and talk about the payment landscape. For many years, we as a field have been working towards a value based care and alternative payment models, not with a whole lot of success, with some success. Certainly there have been pockets of transformation. What does it look like at Augusta Health, and how are you thinking about that? 00;06;47;21 - 00;07;12;12 Mary Mannix It's a great question. And we knew that this movement away from fee for service into value based models was going to be a really important part of our experience curve in our learning curve. So believe it or not, ten years ago we sat down with our board and said, we think that we really need to conceptualize this as kind of a research and development time for Augusta Health, and that we need to get into the ACO space. 00;07;12;12 - 00;07;38;26 Mary Mannix I'm going to be honest with you, Michelle. I didn't even fully understand what an ACO was, but I knew that strategically that was the direction we needed to go. We needed to educate ourselves. And so we actually applied way back in 2014 for the Medicare Shared Savings Program. Worked with a consultant to help us complete the application and understand some of the infrastructure that was going to be required, and then began to develop the resources for population health management. 00;07;38;28 - 00;08;01;03 Mary Mannix We've been through three cycles now with Medicare Shared Savings Program, so we've been in it now for over ten years and have moved from the one-sided upside only model all the way to where we are today. Fast forward, and we are now in the enhanced model where we are doing two-sided risk. We're about to get our fourth year of shared savings. 00;08;01;05 - 00;08;27;00 Mary Mannix We have learned a lot on this journey. We've learned about how to become competent and understand attribution, complexity coding, chronic disease management and especially as it relates to lived life, social determinants of health. The integral role of not only the primary care physician, but the case manager who's really effective at social complexity. We've developed the analytical tools and the platforms. 00;08;27;00 - 00;08;56;12 Mary Mannix We've mapped out areas of deprivation and worked with many community partners to begin to address these gaps. So today, we're a smaller ACO. We have probably a little over 8000 Medicare beneficiaries. We have over 300 providers, and we probably have about 100 million of Medicare revenue running through our ACO. But we've learned a lot, and our quality scores range anywhere from between 94 and 98%. 00;08;56;14 - 00;09;30;05 Mary Mannix Our cost per beneficiary is well below that of the average of all ACOs in the country. And as I said, this has positioned as well. And for the last three years, and soon to be the fourth year, we will have meaningful shared savings that will be able to distribute to those practices that participate in our ACO. What's interesting to me is that I feel like CMS has kind of been leading the pack here, and that our commercial partners have been a little less interested, have been not as eager to move into that experience curve, although their interest is certainly peaking. 00;09;30;08 - 00;09;57;05 Mary Mannix But we find that commercial insurers really don't necessarily have the sophistication, the reliable and valid data management tools. And in our experience, the strength of commercial insurers ability to lead and partner and service these two-sided risk models, quite frankly, is inferior to CMS. We are working with our commercial insurers, our partners, and we have a couple, you know, very successful alternative payment models with them. 00;09;57;05 - 00;10;16;28 Mary Mannix But I really feel like we've come the furthest with CMS and now we're in that enhanced program. So our risk is 75% up or down. And again we've been able to move across these now for enrollments with the Medicare shared savings program to more narrow corridors of risk because we've become more competent in population health management. 00;10;17;00 - 00;10;37;11 Michelle Hood You know, interestingly, when I was with Northern Light Health, we were an early adopter of ACO as well. But I actually had to go to Baltimore to convince CMMI that we could do it in rural Maine, and obviously did convince them that that was possible. And I think, you know, rural communities have some advantage. Rural providers have some advantage. 00;10;37;13 - 00;10;50;10 Michelle Hood They have lifelong patients that have been with them for the entirety of their life, sometimes multi-generational. They have great community partnerships. They know the social determinants issues really, really well. 00;10;50;10 - 00;11;01;25 Mary Mannix So I couldn't agree with you more. They know their communities. They feel better than any other model, quite frankly, of health care. And they're nimble and they're agile because of their lack of scale. 00;11;01;25 - 00;11;22;19 Michelle Hood Yeah, they have to be. Yeah. Yeah, absolutely. Well, we're going to turn to the question of your independence. You are quick to tell us that you are one of the few remaining independent hospitals in Virginia. I know that that can be lonely at times, but you have done a great job with that and continue to strengthen your position. 00;11;22;21 - 00;11;32;29 Michelle Hood So tell us about how you do that. I know you partner with a lot of organizations and you're a great collaborator, but what do you think it is? It's making you successful as an independent provider? 00;11;33;01 - 00;12;02;01 Mary Mannix I think it starts with our governance model. We have a board of directors of 16 individuals that live in the community, and so they're very much in touch with the community. And that is an incredibly high accountability model or strong accountability model. We don't make tough decisions and then they go off to different communities to live. They live with the consequences and really think through deeply all of the really important sort of bet-the-farm decisions that health care is faced with. 00;12;02;04 - 00;12;25;03 Mary Mannix That model of accountability, I think, is where it all begins. There's a tremendous amount of pride in the model that comes from the medical staff, the medical community that comes from our team members, that I also think is really important and critical to keeping everybody engaged in this model of care. We're a sole community hospital, but we only have one hospital, a 255 bed hospital. 00;12;25;03 - 00;12;58;13 Mary Mannix And the rest of what we do is really on an outpatient basis. I mentioned we've got unemployed physician network of 260 providers. We have 35 regional sites of primary care, subspecialty care, kind of diagnostic and treatment or urgent care. And so we're providing the continuum. The other thing that I think is probably critical to our success, and that comes back to governance, is that our board has made the decision that we're going to take 5% of our investment portfolio and sort of seal it off into an endowment, and it's called the Community Partnership Endowment. 00;12;58;16 - 00;13;29;00 Mary Mannix And the proceeds of that endowment go toward health equity opportunities that are our identified youth scholarship in our community, but most importantly, to provide grants to not for profit partners that are aligned with us in improving the health of the community by focusing on our community health needs assessment and what those top 3 to 4 issues are. And this has really kind of become a flywheel, if you will, of community collaboration and partnership. 00;13;29;02 - 00;13;56;04 Mary Mannix And, you know, we have other partnerships as well. You know, we're part of the Mayo Clinic Care Network, which provides great affiliation for resources. Second opinions. We're an affiliate of Duke Oncology Network for Clinical Research for our oncology service line, and we partner with our legislators and our local governments. We have very important partnerships at the state level, you know, with the Department of Health, and we partner with other foundations in the region. 00;13;56;06 - 00;14;14;01 Mary Mannix So I feel like this model of collaboration, really knowing our community, sort of it all beginning with governance and making a lot of inroads into our community through these partnership models, are probably the most important critical success factors to our ability to hopefully sustain our mission for many generations to come. 00;14;14;04 - 00;14;39;17 Michelle Hood That doesn't come without a lot of hard work, so congratulations on that. One of the other things that I know you and I share is our desire to be really strong advocates, to increase the role for women in health care leadership. We see many more women CEOs today than we have in the past, and I see a lot of young women coming up in the ranks who are really promising. 00;14;39;19 - 00;14;53;06 Michelle Hood So interested in how you think the opportunities for women have developed over the years, and how we can continue to open doors for young women, but also other minorities who are underrepresented in our vocation. 00;14;53;08 - 00;15;16;17 Mary Mannix One of our speakers this morning said, diversity is knowledge, and I just think that that is so true. You know, as women, Michelle, I think we need to remain networked and actively involved in mentorship relationships with our female colleagues at a very intentional level. We need to take risks with our female colleagues and other minorities for succession planning and leadership development. 00;15;16;20 - 00;15;43;12 Mary Mannix And I really feel like we need to encourage our colleagues, female and other minorities, to sort of take that next step of professional development and responsibility even if you don't feel 100% ready. It's okay to come out of your comfort zone and get into your discomfort zone. I also think we need to talk openly about phenomenon that hold back high performing executives, you know, things like imposter syndrome and, you know, these other cognitive distortions. 00;15;43;12 - 00;16;12;08 Mary Mannix We need to get those out in the open and tame that emotion by acknowledging its presence and coach and mentor and just reframe around growth and, quite frankly, self-kindness. I think we have to certainly advocate for greater parity in our field across the board, whether that is in fair market value compensation or the types of networking activities that previously have been very gender oriented, whether it be the golf tournament or, you know, what have you. 00;16;12;10 - 00;16;33;23 Mary Mannix And, you know, I look forward to the day when a health care system CEO is simply a health care system CEO, not necessarily a female CEO, but a health care system CEO. And, you know, it's my hope that we're paving the way for our daughters and that our daughters will continue to pave the paths that we've started. And I think they're going to do that. 00;16;33;23 - 00;16;57;08 Michelle Hood That's well said, really well said. So I want to thank Mary for sharing her thoughts on the challenges of rural hospitals and health systems, and the challenges that must be overcome to assure a viable and robust rural health care delivery system for the future. I know our listeners appreciate the credibility you bring through a lifetime of experience as a clinician, administrator and leader in rural health care. 00;16;57;11 - 00;17;07;19 Michelle Hood I am Michelle Hood, executive vice president and chief operating officer of the �� Association. Thank you for listening. This has been an Advancing Health podcast. 00;17;07;21 - 00;17;16;01 Tom Haederle Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts. </details></div> Fri, 21 Jun 2024 08:17:31 -0500 Accountable Care Organizations (ACOs) CMS accepting applications for ACO Primary Care Flex Model /news/headline/2024-05-31-cms-accepting-applications-aco-primary-care-flex-model The Centers for Medicare &amp; Medicaid Services is <a href="https://www.cms.gov/files/document/aco-pc-flex-rfa.pdf">accepting applications</a> until Aug. 1 for the Accountable Care Organizations Primary Care Flex Model, a voluntary model that will focus on primary care delivery in the Medicare Shared Savings Program. The model will test how prospective payments and increased funding for primary care in ACOs impact health outcomes, quality and costs of care. Interested organizations must <a href="https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos/application-types-timeline">first apply</a> as new or renewing ACOs to the MSSP by June 17. The ACO PC Flex Model will launch Jan. 1, 2025, and run for five years. CMS will host a <a href="https://deloitte.zoom.us/webinar/register/WN_0-RfYgJBSjGuf2OwOrtKiw#/registration">webinar</a> June 6 about the model, and has also developed a <a href="https://www.cms.gov/files/document/aco-pc-flex-fs.pdf">fact sheet</a> and <a href="https://www.cms.gov/priorities/innovation/innovation-models/aco-primary-care-flex-model/faqs">FAQ</a> with more information. Fri, 31 May 2024 15:02:04 -0500 Accountable Care Organizations (ACOs) Letter to CMS Administrator Brooks-LaSure on the Higher Spending on Two Catheter Codes and the Impact on ACOs /lettercomment/2024-04-30-letter-cms-administrator-brooks-lasure-higher-spending-two-catheter-codes-and-impact-acos <div class="container"><div class="row"><div class="col-md-8">April 29, 2024The Honorable Chiquita Brooks-LaSure Administrator Centers for Medicare &amp; Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445–G 200 Independence Avenue, SW Washington, DC 20201</div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf" target="_blank" title="Click here to download the Letter to CMS Administrator Brooks-LaSure on Higher Spending on Two Catheter Codes and the Impact on ACOs PDF.">Download the Letter PDF</a></div></div></div><div class="row"><div class="col-md-8">Dear Administrator Brooks-LaSure:The undersigned organizations write to request that accountable care organizations (ACOs) are held harmless from anomalous Medicare spending outside their control, such as the aberrant billing for catheters experienced in 2023. We sincerely appreciate the efforts the Centers for Medicare and Medicaid Services (CMS) has taken over the last several years to advance its value-based care strategy. With growth a central part of the strategy, it is critical to ensure that clinicians, hospitals, other healthcare providers and ACOs can remain in the models to best serve patients through accountable care. Including anomalous Medicare spending penalizes ACOs for expenditures outside their control and jeopardizes their continued participation.Given their focus on promoting high-quality and efficient care, ACOs are well positioned to partner with CMS as good stewards of the Medicare program. ACOs regularly analyze Part A, B and D claims on their assigned patients to find gaps in patients’ care, opportunities for clinical interventions, and trends in costs and utilizations in their populations overall. It is through these efforts that ACOs recognize anomalous spending and report suspected fraudulent billing to CMS and the HHS Office of Inspector General (OIG). We appreciate ongoing efforts by CMS and the HHS OIG to look into these reports of fraud.In 2023, ACOs noticed significantly higher spending for two catheter codes. The Institute for Accountable Care analyzed Medicare claims for these two codes from the CMS Virtual Research Data Center and discovered a nearly 20-fold increase in just two years, with spending increasing from $153 million in 2021 to $3.1 billion in 2023. Furthermore, almost all the increase was attributed to just 10 suppliers. The impact to ACOs is serious as this spending is unaccounted for in ACO financial benchmarks. While national trend updates in the ACO programs will account for anomalous spending that occurs nationwide, the impact of the high catheter spending varies greatly from region to region. Accordingly, national trend updates will not help ACOs whose catheter spending on their patients is above national averages. Additionally, data from the Institute for Accountable Care show that nearly half of ACOs in 2023 had catheter spending on their assigned patients that was greater than that of their region. Almost 10% had an average of nearly $50 per patient per year more than their regional average, and 5% of ACOs would see an impact ranging from $166 per patient per year to well over $1,000 per patient per year. Accordingly, these ACOs’ spending is affected far more than would be captured by the regional-national spending trends used to update their benchmarks — which would lead to a loss of shared savings.We ask that CMS hold ACOs harmless from anomalous spending. Akin to the COVID-19 Public Health Emergency, this spending is far outside of the control of any clinician, hospital, other provider, or organization engaged in population health management. To hold ACOs harmless from the anomalous catheter spending in 2023, we ask that CMS take the following actions as part of performance year 2023 reconciliation:<ul><li>Remove catheter expenditures from ACO financial calculations. ACO benchmarks are meant to be a fair estimate of expected patient spending, based on the historic spending of aligned beneficiaries, adjusting for regional spending and relative risk of patients, then trended forward to reflect national and regional updates in Medicare spending. The recent catheter billing issue is increasing some ACOs’ total spending by as much as 2%. Leaving financial calculations unadjusted distorts performance and financial benchmarks, creating an apples-to-oranges comparison for both ACOs and CMS. Moreover, program integrity officials have signaled that this spending is under active investigation, with some of these payments for suspect claims in escrow. Given the ongoing investigation, the fairest way to handle for ACOs and CMS is to remove these questionable claims from all ACO financial calculations, including historic benchmarks, trend updates, and performance year expenditures. At a minimum, we request that CMS remove claims in escrow from ACO financial calculations as these are claims that CMS has already deemed suspicious. Therefore, ACOs should not be held accountable for this spending.</li><li>Create an outlier policy to account for other similar variation in anomalous spending. CMS should look at outlying spending patterns and remove those services from ACO financial calculations. For example, CMS could remove services from ACO financial calculations if spending for those services surpasses some pre-determined threshold. CMS has precedent for outlier policies across the Medicare programs and uses a similar policy for ACOs, truncating spending for any individual patient in the 99th percentile. But that applies to individual patients, not services. The 2023 catheter spending is not the first, and is unlikely to be the last, instance of ACOs reporting suspected fraudulent billing. For example, ACOs have also reported spikes in spending for diabetic supplies and skin substitutes, which may also fall under a potential outlier spending policy. To prevent similar issues in future years, CMS should consider implementing a permanent outlier policy at the service or billing code level.</li><li>Provide ACOs an option for a second reconciliation. We recognize that fraud investigations by CMS and the HHS OIG can take years and may not conclude until well after an ACO’s financial reconciliation. In the past, ACOs have reported suspected fraud and then years later learn that fraud was confirmed. This timeline introduces harm for ACOs as they are held accountable for the fraudulent spending. To help, CMS should provide an option for ACOs to elect to have a second reconciliation once the Federal government has concluded if a claim was fraudulent. CMS reserves the right to reopen determinations of ACO shared savings or shared losses in §425.315.</li></ul>We strongly urge CMS to address these policies for the Medicare Shared Savings Program (MSSP), in the upcoming Medicare Physician Fee Schedule proposed rule, and the ACO Realizing Equity, Access, and Community Health (REACH) Model, which doesn’t need formal rulemaking. There is precedence for making such policy changes after a performance year ends. In the <a href="https://www.federalregister.gov/d/2023-24184/p-2942" target="_blank">2024 Medicare Physician Fee Schedule</a>, CMS finalized a retrospective policy for the MSSP, specifically the underserved multiplier in the health equity adjustment for MSSP starting in performance period 2023. CMS justified the change by saying Section 1871§ (1)(A)(ii) of the Social Security Act authorizes CMS to retroactively apply a substantive change in regulations if it determines that failure to apply the change retroactively would be contrary to the public interest. CMS stated absent a change “current policy may unfairly penalize ACOs for reasons beyond their control.” The same logic easily applies to the anomalous 2023 catheter billing situation.We also request that CMS continue to work with stakeholders on long-term solutions to address suspected and confirmed fraud. As stated above, ACOs are well positioned to detect anomalous billing given their in-depth examination of claims data. As the HHS OIG has <a href="https://oig.hhs.gov/oei/reports/oei-02-15-00451.asp" target="_blank">previously noted</a>, ACOs are excellent sources to uncover potential fraud, waste, and abuse by identifying patterns of unusual billing. The HHS OIG noted that CMS should provide a heightened level of attention to ACO referrals. The undersigned organizations and ACOs are willing partners in promoting program integrity. For example, there are both opportunities to improve how ACOs report fraud, as well as to better educate ACOs on the process CMS and the HHS OIG undertake to investigate fraud. We look forward to discussing opportunities to better leverage ACOs, including these issues and our recommendations.Thank you for your continued leadership in supporting the movement to value-based care, we appreciate your consideration of our concerns.Sincerely,Accountable for Health America’s Physician Groups �� Association American Medical Association AMGA Association of American Medical Colleges Federation of ��s Health Care Transformation Task Force Medical Group Management Association National Association of ACOs Premier, Inc.</div><div class="col-md-4"><a href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf" target="_blank" title="Click here to download the Letter to CMS Administrator Brooks-LaSure on the Impact of Higher Spending on Two Catheter Codes and the Impact on ACOs PDF."><img src="/sites/default/files/inline-images/Page-1-Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.png" data-entity-uuid="58a302bb-0e44-4957-8a5e-78c50366bd7e" data-entity-type="file" alt="Letter to CMS Administrator Brooks-LaSure on Higher Spending on Two Catheter Codes and the Impact on ACOs page 1." width="695" height="900"></a></div></div></div> Tue, 30 Apr 2024 15:52:20 -0500 Accountable Care Organizations (ACOs)