ACOs for spe­cialty providers could be key to sav­ing Medi­care money

Modern Healthcare - - NEWS - By Vir­gil Dick­son

While peo­ple were closely watch­ing re­sults from the Medi­care pro­gram’s pri­mary-care-fo­cused ac­count­able care or­ga­ni­za­tion mod­els—the Pi­o­neer and the newer Nex­tGen—a group of ACOs tar­get­ing re­nal care reaped the big­gest sav­ings of all.

Last year, the Com­pre­hen­sive EndS­tage Re­nal Dis­ease Care Model saved $75 mil­lion, ac­cord­ing to the CMS. That’s more than the $68 mil­lion saved by Pi­o­neer ACOs or the $48 mil­lion saved by Nex­tGen ACOs in the same pe­riod.

The re­nal care ACO model’s per­for­mance has some talk­ing about ex­pand­ing value-based pay­ment ap­proaches.

“Th­ese find­ings sup­port the need for more spe­cialty pay­ment mod­els,” said Christo­pher Huryn, a health­care lawyer at the law firm Brouse McDow­ell. “The most po­ten­tial sav­ings ex­ist in the med­i­cal spe­cial­ties that pro­vide, and in the pa­tient pop­u­la­tions that re­quire, the most costly care.”

Most value-based pay mod­els avail­able now tar­get pri­mary-care ser­vices, leav­ing few op­tions for other providers to earn bonuses if they im­prove qual­ity of care for pa­tients while low­er­ing costs. But the 2016 re­sults show there could be un­tapped po­ten­tial for spe­cialty- and dis­ease-fo­cused ACO mod­els.

“The big saver, by far,” was the end-stage re­nal dis­ease model, said David Muh­lestein, chief re­search officer at Leav­itt Part­ners. “Per­haps there is more op­por­tu­nity to fo­cus on dis- ease-spe­cific pro­grams.”

The ESRD model may have out­per­formed oth­ers be­cause of the way the pro­gram is struc­tured; par­tic­i­pat­ing providers knew up­front that they were ac­count­able for spe­cific pa­tients.

In other ACO mod­els, pa­tients are retroac­tively as­signed to the pro­grams at the end of the year, Muh­lestein said.

The CMS launched the re­nal dis­ease ACO model af­ter see­ing ris­ing costs of care for Medi­care ben­e­fi­cia­ries with end-stage re­nal dis­ease. Be­tween 2013 and 2014, Medi­care fee-for-ser­vice spend­ing for ben­e­fi­cia­ries with ESRD rose 3.3% to $32.8 bil­lion, ac­count­ing for 7.2% of over­all Medi­care paid claims costs.

Th­ese in­di­vid­u­als typ­i­cally have many health prob­lems, are at higher risk of hos­pi­tal read­mis­sions and suf­fer from frag­mented care, the agency said.

Providers could find fi­nan­cial suc­cess us­ing an ACO that tar­gets spe­cific car­diac pro­ce­dures, ac­cord­ing to Dr. Keith Naun­heim, chief of car­dio­tho­racic surgery at St. Louis Uni­ver­sity School of Medicine.

In 2012, di­rect med­i­cal costs for heart fail­ure in the U.S. to­taled $20.9 bil­lion, and that’s ex­pected to hit $53.1 bil­lion by 2030, ac­cord­ing to re­searchers. Conges­tive heart fail­ure was the most com­mon con­di­tion for Medi­care read­mis-

The CMS launched the re­nal dis­ease ACO model af­ter see­ing ris­ing costs of care for Medi­care ben­e­fi­cia­ries with end-stage re­nal dis­ease.

sion in 2014, with 134,500 ben­e­fi­cia­ries re­hos­pi­tal­ized for a to­tal cost of more than $1.7 bil­lion, ac­cord­ing to HHS’ Agency for Health­care Re­search and Qual­ity.

While pri­mary- care providers must track a va­ri­ety of ail­ments for each pa­tient, car­di­ol­o­gists’ work is more tar­geted, mak­ing it eas­ier for them to track qual­ity of care, Naun­heim said.

Car­di­ol­o­gists and heart sur­geons want to be re­warded for im­prov­ing the qual­ity of care for pa­tients while low­er­ing costs, much like their pri­mary-care col­leagues. But the CMS un­der Pres­i­dent Don­ald Trump ap­pears to have soured on the con­cept and has pro­posed can­cel­ing three in­cen­tive mod­els based on bun­dled pay­ments tar­get­ing coro­nary artery bypass and car­diac re­ha­bil­i­ta­tion that were sched­uled to be­gin on Jan. 1, 2018.

If that de­ci­sion is fi­nal­ized, car­diac providers won’t have an al­ter­na­tive pay model of their own to par­tic­i­pate in, ac­cord­ing to Dr. Richard Prager, pres­i­dent of the So­ci­ety of Tho­racic Sur­geons.

De­spite an in­ter­est in value-based mod­els, not all car­diac providers are in­ter­ested in an ACO and in­stead would pre­fer a bun­dled-pay­ment model like those fac­ing can­cel­la­tion.

Those mod­els are more pro­ce­dure-based and track the health out­comes of a pa­tient post-surgery, ac­cord­ing to Dr. Wil­liam Bor­den, chief qual­ity and pop­u­la­tion health officer at Ge­orge Washington Uni­ver­sity’s Med­i­cal Fac­ulty As­so­ci­ates.

IS­TOCK PHOTO

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