Healthcare Town Hall

Yesterday, Health & Human Services announced 89 new accountable care organizations (ACOs), doubling the number of Medicare ACOs.

With this in mind we’ve pulled together all of our ACO research into a single location. Here you go:

• Accountable care organizations: The new provider model
• Controlling healthcare costs the old, new way
• The Medicare Shared Savings Program and the Pioneer Accountable Care Organizations
• Building an accountable care information system
• The nurse’s role in accountable care
• Nuts and bolts of ACO financial and operational success
• Evidence-based guidelines: Essential building blocks for accountable care
• ACO gain/loss sharing
• Patient attribution in ACOs
• ACOs and medical professional liability
• Milliman’s announcement that it has been selected for a Society of Actuaries-sponsored ACO research study

 
Also, this video offers a nice overview of the ACO concept.

Electronic Health Records ACOs, Bill O'Brien, George Berry, Helen Blumen, Kate Fitch, Patty Jones, Rich Moyer, Richard Kipp, Rob Parke, Susan Pantely, Victoria Boyarski

With accountable care organizations (ACOs) soon to serve more than a million Medicare patients, it is clear that this model of care delivery is receiving an unprecedented test of its viability, and, if it works as intended, may reshape how healthcare is paid for on a larger scale. Cigna alone plans to have more than a million people enrolled in ACOs by 2014, and says it believes that ACOs are going to be important regardless of the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA).

With so much focus on the topic, it’s worth taking a look back at some of the research and analysis on ACOs published by Milliman on the topic over the past couple of years.

First, for a good summary of ACOs—what they are and how they work—start with this overview video featuring a number of Milliman experts.

For many observers, the key question about ACOs is whether they represent a financially viable model compared to fee-for-service. Effective financial management will be key to success. Milliman has produced a number of relevant papers:

• “Nuts and Bolts of ACO Financial and Operational Success: Calculating and Managing to Actuarial Utilization Targets” provides significant operational detail on dealing with utilization in an ACO context.
• “ACO Gain/Loss Sharing” proposes a framework for allocating savings within an ACO that emphasizes rewards for an ACO’s component entities based on their relative contributions to the organization’s total shared savings and quality performance. Such a framework is required when applying as a Medicare ACO, but the Centers for Medicare and Medicaid Services (CMS) has not provided a detailed procedure for creating one. This paper tries to help fill that gap.
• “A First Look at ACO’s Risky Business: Quality Is Not Enough” discusses downside risk faced by Medicare ACOs; while somewhat dated at this point it still contains some useful concepts.
• “Pioneer ACOs: Quantifying Risks and Identifying Opportunities” focuses on how Pioneer ACOs can control costs and identify savings opportunities given the additional risks they face.

 
With all the attention on Medicare ACOs, it’s easy to forget that they exist in the private market, as well. For more on such entities, look at “ACOs Beyond Medicare,” which describes the potential advantages for providers who partner with a private insurer rather than with CMS. A 2011 Managed Healthcare Executive roundtable featuring Milliman consultant Rob Parke also discussed ACOs in the private market.

A number of other papers have also been published discussing various aspects of ACOs such as:

• The use of care management guidelines in managing ACOs
• Patient attribution
• The role of nurses in accountable care

Reform Bruce Pyenson, Cathy Murphy-Barron, David Mirkin, Helen Blumen, Howard Kahn, Kate Fitch, Patty Jones, Rob Parke, Susan Pantely, Tiffanie Lenderman, Victoria Boyarski; ACOs

With the proposed accountable care organization (ACO) regulations issued yesterday, it’s all eyes on ACOs. This video captures the cost challenge and explores how ACOs may offer a solution.

We have a large library of ACO materials–you’ll find them here. Highlights include papers and posts about:

• Patient attribution
• ACO nuts and bolts
• The role of evidence-based guidelines
• Building an accountable care information system 
• Cancer-focused ACOs
• And here are a few key terms

Check back soon for more on ACOs and the new regulations.

Cost, Quality of Care ACOs, Clark Slipher, Ed Cymerys, Rich Moyer, Rob Parke, Stu Rachlin, Susan Pantely, Tom Snook

The accountable care organization (ACO) model, like the HMO model, aims to promote provider accountability for care coordination. However, in an ACO, there is no gatekeeper primary care physician (PCP), and members can seek care from any provider they choose. In order to measure provider performance in such a system, members must be assigned to providers via an analysis of healthcare claims. Patient attribution methods that support valid and actionable cost and quality metrics will be crucial to the development of an effective ACO model. A new paper by Susan Pantely looks at patient attribution in ACOs.

Accountablity, Cost ACOs, Susan Pantely

The American Medical Association has had a tech-friendly couple of weeks. Last week they announced  the availability of online resources to support e-prescribing efforts. They have also joined Twitter.

The social networking news may be getting the headlines, but the support for e-prescribing may have more immediate benefit. Milliman principal Susan Pantely published an article about the benefits of e-prescribing earlier this year. e-Prescribing has a number of efficiency and quality implications and can enable better access to necessary prescriptions for patients and better management of prescriptions for providers.

Efficiency, Electronic Health Records, Portablity, Quality of Care e-prescribing, Susan Pantely

Milliman experts and their research are increasingly a part of Congressional discussions of healthcare reform. On Tuesday, AHIP President and CEO Karen Ignagni cited research by Will Fox and John Pickering in her testimony before the Senate Health, Education, Labor and Pensions Committee:

A December 2008 study by Milliman, Inc. projects that this cost shifting essentially imposes a surtax of $88.8 billion annually on privately insured patients, increasing their hospital and physician costs by 15 percent. This study concluded that annual health care spending for an average family of four is $1,788 higher than it would be if all payers paid equivalent rates to hospitals and physicians. The transfer of these costs to those with private coverage cannot be sustained and is critical to addressing concerns over affordability.

Read more…

Cost, Fragmented system, Government, Long Term Care, Reform Bruce Pyenson, Congress, cost shift, John Pickering, Kate Fitch, Long Term Care, Susan Pantely, Will Fox