center for medicare and medicaid innovation & acos

Creation of the Center for Medicare and Medicaid Innovation & ACOsAdele Allison,National Director of Government Affairs, SuccessEHS

Created under §3021 of Patient Protection & Affordable Care Act

$10 Billion allocated for FY2011 - 2019

Focus on Government Health Programs

Medicaid, Medicare, Children’s Health Insurance Program

Empowered by Congress

-Flexibility in selecting and testing new payment models-Secretary allowed broad discretion in rulemaking

Spotlight on decreased costs & increased quality

Four Mission Domains1. Patient Care Models

-Bundled Payments2. Seamless & Coordinated Care Models

-ACOs & PCMHs

Four Mission Domains3. State Engagement Models

-1,200 medical homes; Medicaid Health Home State Plan (2 years 90% funded for chronic dz. or mental illness)4. Community & Population Health Models

-Public Health (ex: smoking, obesity)

CMMI & ACOs

PPACA requires CMS to start contracting CY2012

What is an Accountable Care Organization (ACO)?“Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.”

Three types of CMMI ACOs1. Shared-Savings ACO2. Advanced Payment ACO3. Pioneer ACO

ACO Final Rule: Applications open Jan. 1, 2012

Two initial launch dates: April 1, 2012 &July 1, 2012

CMS anticipates 270 ACOs to form

Medicare Shared-Savings ACO

Heart of the ACO Final Rule issued Oct. 20, 2011

Minimum 5,000 Medicare PFS Beneficiaries

Two ModelsOne-Sided, No Risk = 50% sharing in savings created

Two-Sided, Limited Risk = 60% sharing in savings created

One-Sided-Physicians paid FFS, as usual-If savings is created AND performance measures achieved, 50/50 split-If ACO exceeds per capita benchmark, no downside

Two-Sided-Physicians paid FFS, as usual-If savings is created AND performance measures achieved, 60/40 split-If ACO exceeds per capita benchmark, fee adjustment occurs (capped)

Advanced Payment ACO

Created to help MD-owned and/or Rural Providers

Limited to Two Organizational Types 1. ACOs with no inpatient and annual revenue of < $50 million2. ACOs with inpatient through CAHs/Rural hospitals and revenue of < $80 million

Three Payment Types1. Upfront Fixed Payment2. Upfront Payment based on historically-assigned beneficiaries3. Monthly Payment based on historically-assigned beneficiaries

ACO application must be made for both Shared-Savings and Advanced Payment

No health plan ownership allowed

Pioneer ACO

Created for Advanced Health Organizations

Minimum 15,000 aligned beneficiaries

Not subject to the ACO Final Rule – Separated Model

Intent of the Model-Allow advanced systems to move quickly to population-based payment model

-Work in coordinating model with private payers to align quality and outcome incentives

Pioneers would have a higher share in savings created

Pioneers also have a higher share in risk

Pioneers have broadened control over community-based rewards and consequences

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