ACOs for specialty providers could be key to saving Medicare money
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.