Next Generation ACO Model: Conversation With Industry Executives

Today’s Wound Clinic recently reached out to those participating in the CMS Next Generation ACO Model. Here’s what members of various hospital executive teams had to say about their participation in this initiative and their expectations of membership. 

The Centers for Medicare & Medicaid Services (CMS) has launched a new accountable care organization (ACO) model — the Next Generation ACO model. The 21 ACOs participating in this model in 2016 have significant experience coordinating care for populations of patients through initiatives including, but not limited to, the Medicare Shared Savings Program (MSSP) and the Pioneer ACO model. Building on experience from the Pioneer ACO model and the MSSP, CMS will partner with ACOs that are experienced in coordinating care for populations of patients and whose provider groups are ready to assume higher levels of financial risk and reward through this new model. This is in accordance with the administration’s goal of tying 30% of traditional (or fee-for-service [FFS]) Medicare payments to alternative payment models, such as ACOs, by the end of 2016 — and 50% by the end of 2018.

Medicare ACOs have grown to more than 477 nationwide, currently serving nearly 8.9 million beneficiaries since the Medicare Shared Savings Program and Pioneer ACO model began in 2012. The results from the past four years have demonstrated that ACOs can provide better quality of care for beneficiaries while producing savings, according to CMS officials.

Next Generation ACO Background

The Next Generation model is an initiative for ACOs that are experienced in coordinating care for populations of patients that will allow provider groups to assume higher levels of financial risk and reward than are available under the current 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 FFS beneficiaries, according to CMS officials.

Included in the Next Generation model are strong patient protections to ensure patients have access to and receive high-quality care. Like other Medicare ACO initiatives, this model will be evaluated on its ability to deliver better care for individuals, better health for populations, and lower growth in expenditures. CMS will publicly report the performance of the Next Generation ACOs on quality metrics, including patient experience ratings, on its website: www.cms.gov. The model will consist of three initial performance years and two optional one-year extensions. 

As part of this special edition of Today’s Wound Clinic focusing on the future of reimbursement and billing, we spoke with executive officials throughout the Next Generation ACO network about their expectations related to ACO membership, their respective organizations’ roles within their ACOs, and the impact that outpatient wound care could have for all patients and providers involved. 

Sheila Johnson, RN, MBA, vice president, population health clinical operations, Trinity Health, Livonia, MI 

Who are the members of your ACO? “Employed and affiliated providers who are part of our clinically integrated networks in six locations: Affinia Health Network (Muskegon, MI, and Grand Rapids, MI); Mount Carmel Health System (Columbus, OH); Lourdes Health System (Camden, NJ [and LHS Health Network]; Loyola Physician Partners (Maywood, IL); Loyola University Health System (Maywood, IL); and Summit Medical Group (Berkeley Heights, NJ).”

Please discuss what makes the ACO unique, and please detail your organization’s role within it. “Trinity Health’s ACO is made up of five chapters consisting of providers located in four states. This is our first national ACO — one that spans more than one community where Trinity Health has a presence.” 

How is your ACO payment structured? “We continue to receive traditional FFS payments for the care we provide, but also are compensated for good performance and penalized for poor performance. The Next Generation ACO program is designed to reward ACOs that achieve the ‘Triple Aim’ — better health, better care, and lower cost. As in other ACO programs, you must meet specific measures including lowering the total cost of care or reducing the number of care visits. When our ACO demonstrates that we have provided quality care, as evidenced by performance on 34 quality measures, we are eligible for shared savings from the government. New with this program is that we are at risk for any financial losses — meaning we will pay a penalty to the government if we don’t lower the cost of care or meet quality measures. This is a major change from Pioneer ACOs.”

How are quality measures tracked? “Quality measures are split into four domains: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations. Within these four domains, 34 specific measures are tracked.” 

How did CMS provide you with your ACO patients? “Physicians and associate providers enroll with CMS to be a participating provider in the ACO. CMS applies an algorithm to claims data to align beneficiaries with the participating provider. Medicare beneficiaries with a standard Medicare plan are eligible to be aligned with the ACO. Generally, the beneficiaries are already cared for by our participating physicians, and hence they are aligned to our ACO.”

How is the ACO aligning with healthcare reform? “Trinity Health is embracing new payment arrangements and care models. ACOs are at the forefront of care innovation and patient-centered care. Within an ACO, we are better equipped to manage complex and chronic health conditions, along with episodic care. We are able to manage our patient population more efficiently and make sure we provide the right care, at the right time, and at the right place.”

Was your hospital responsible for hiring any of the QHPs who may have had independent practices as part of the ACO? “Our health system has affiliate providers who have joined our clinically integrated networks (CINs), but are not employees of Trinity Health. We have worked diligently to partner with independent physicians who add value to our CINs and agree to provide quality, cost-effective care and to implement clinical quality measures and reporting.” 

Are you involved in any other risk-sharing contracts with private payers? “Yes, including with our own colleagues (employees).”

Were you a member of a Pioneer or any other ACO prior to your current model? “Yes, we were a member of and continue to participate in the MSSP ACO model.”

What are the differences between your former and current ACO structure/payment? “The biggest change with the Next Generation ACO model is the addition of downside financial risk, meaning we pay a penalty to the government if we don't lower costs and meet quality standards.”

Why do you anticipate your organization will be clinically and financially successful within your current ACO? Where does the outpatient wound clinic come into play in this regard? “We will be successful because of our past experience participating in ACOs and because we are committed to becoming a people-centered health system. Trinity Health believes we will always be in the business of providing care for people in the acute setting, but we also know we will be expected to care for people in a better way. We want to manage chronic disease before it becomes an acute problem that lands a patient in the hospital. It is part of our service delivery and model of care — working as a unified group and to make sure the patient stays healthy and has access to highly trained health professionals when needed.”

What has been the most significant impact on your outpatient wound program since the ACO formed? “This is an area of opportunity for us at Trinity Health. We hope that as we continue to grow our ACO models that it will be more fully integrated into care management. We anticipate that patients at risk for wounds due to chronic conditions or other reasons will be actively engaged with care managers and wound care professionals as we move forward.”

What have been the financial impacts? “We’ll be better able to answer this question in the future, when we have that data.”

Charles Kelly, DO, executive, Henry Ford Physicians ACO; CEO, Henry Ford Physician Network, Detroit 

Who are the members of your ACO? “Six hospitals; more than 1,600 physicians including 1,100 in the Henry Ford Medical Group, 200 regionally employed physicians, and more than 300 private-practice physicians; 52 skilled nursing facilities (SNFs) are listed as participants; and five home health agencies.”

Please discuss what makes the ACO unique, and please detail your organization’s role within it. “This ACO is unique in that it has significant downside risk, offers several new tools made available to ACOs, including telehealth waivers, and directs SNF admits and expanded home visits. Our role is advancing the population health infrastructure platform to drive Henry Ford’s success across all value-based contract arrangements.”

How is your ACO payment structured? “Traditional fee-for-service with prepaid $6 per member, per month, upfront infrastructure payments.”

How are quality measures tracked? “Within our common EHR – Epic (Verona, WI).”

How did CMS provide you with your ACO patients?

“Attribution to aligned physicians based on 2014 preponderance of primary care codes.”

How is the ACO aligning with healthcare reform?

“Our system strategy is to move to the majority of contracted arrangements to qualify for value-based payment models.”

Was your hospital responsible for hiring any of the QHPs who may have had independent practices as part of the ACO? “Our hospitals have not hired any healthcare professionals as part of our ACO strategy.”

Are you involved in any other risk-sharing contracts with private payers? “Yes.”

Were you a member of a Pioneer or any other ACO prior to your current model? “No.”

Why do you anticipate your organization will be clinically and financially successful within your current ACO? Where does the outpatient wound clinic come into play in this regard? “We already are a vertically integrated organization and all providers have successfully been involved in risk-bearing relationships. Supporting evidence-based medicine is part of our core. The role of the outpatient wound clinic will remain the same in providing optimal care that will result in reduced avoidable hospitalizations and the prevention of wound-related complications.”

What has been the most significant impact on your outpatient wound program since the ACO formed?

“We have only been in the ACO model since Jan 1, 2016. It’s still far too early to evaluate the impacts of any clinical initiatives.” 

For more information on the Next Generation ACO model initiative, visit: https://innovation.cms.gov/initiatives/next-generation-aco-model