Health plans used to chew you down on price and hassle you over hospital admissions. Enter the new age: contracting as an accountable care organization. Medicare started this innovation, and it's spreading to other payers, including Medicaid and private insurers. There's less gnawing on price, little or no hassle on admits, but you face a whole new burden: quality measures.
In addition to all the work you did to create your ACO, your new team has to work together to achieve measured goals. Your ACO will be rewarded if you hit these quality numbers. So it's worth negotiating these measures carefully.Here are some questions you should ask the payer and why:
1. How are patients assigned (or "attributed") to my panel? And how often will I get a patient roster? Contracts will have different criteria for who counts as your patient. Some will put patients who visited you once within the past two years onto your panel. This means patients you barely know could affect your ACO's financial performance. Getting the payer's list of your patients will give you a better handle on who needs attention and who does not.
2. Assuming there is an incentive to manage emergency department visits or hospital stays, is my ACO striving to do better than a benchmark or to lower the visit frequency of our own population? The ACO model is supposed to save money by optimizing (read: reducing) the use of higher-intensity services. The details of how this is measured can make a big difference in your ACO's performance. For example, the benchmark might be based upon privately insured groups, who would have a lower frequency of ED visits than your ACO's Medicaid patients. Risk adjustments can help, but it would be preferable to have a benchmark source that closely matches your patient mix.
3. When and how will patient experience surveys be done? What will be the sample size for my ACO?Medicare's ACO program includes patient satisfaction as a quality measure. Other payers are likely to do the same. It means that your patients will be asked about their care experience; these survey results will weigh in to your incentive payment. Surveys can be problematic for lots of different reasons. Patients may have non-traditional work schedules — working nights, or working on oil rigs or fishing boats that are out to sea two weeks out of every four. Live in a tourist town? Your patients may be working 12-hour days in June, exactly when your payer plans to do the survey. Patients who speak another language at home and come from another culture may have difficulty not just with the words, but also with the idea that a relative stranger is asking personal questions. You want to make sure that appropriate steps are taken to get a truly representative sample of your panel.
There are many other important factors to negotiate on the quality measures, even if the payer assures you that the measures are standard for all contracts. The measures may be standard, but your group of patients is not.
Initial results based upon the quality, utilization and patient surveys look promising. The federal Pioneer ACO program generated $147 million in savings, and half of that went back to the ACOs and providers. There are more than 620 ACOs, according to Leavitt Partners Center for Account Care Intelligence. The number will grow as payers from Medicare to Medicaid to private insurers are lured by the prospect of happier members and lower costs.
Many ACO managers will be tempted to assume that doing their usual excellent work will win the day. The truth is that to succeed, an ACO has to master the measures.
Linda Riddell is a population health scientist, specializing in helping clients apply the latest science to practical questions. She works with public and private payers to maximize the data they have available, and to use it to inform strategic and policy decisions. She has a master’s of science degree in health policy and management from the Muskie School of Public Service, University of Southern Maine. Her undergraduate degree is in English, Phi Beta Kappa from the University of Cincinnati.
Vik Khanna is the Wellness editor at large for The Health Care Blog, the author of over 70 articles and a sought after speaker and consultant on the topics of managed care and wellness. He has a master of health science in health policy & management from Johns Hopkins University School of Hygiene & Public Health and two bachelor of science degrees — both with honors. One is from the Hahnemann Physician Assistant Program at Drexel University and the other in Exercise Science and Physical Education, SUNY Cortland.
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3 lessons learned from MSSP ACOs in performance year 1
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