How does value based care impact your practice?
Health care in the U.S. is changing rapidly, with an increasing number of physicians, health plans, and hospitals embracing the shift to value based care. Across the country, government and commercial payers are offering a wide range of programs aimed at helping physicians improve the cost and quality of care for their patients.
Amidst this complex and changing health care landscape, your practice has an opportunity to improve care for your patients and secure the future of your practice. Success in value based care means healthier patients, better quality care, and more revenue for your practice.
The Basics: ACOs, Medical Homes, and Bundled Payments
Value based care embodies one simple principle: delivering high quality, lower cost care. With a focus on reducing costs, advancing quality, and improving patient experience, providers engaged in value based care can improve the health and wellbeing of their patients and the affordability of their care.
Three prominent value based care models are focused on achieving these goals:
Accountable Care Organizations (ACOs) are groups of physicians, hospitals, and/or healthcare providers focused on delivering coordinated, high quality care at a lower cost. These organizations participate in government or commercial agreements that increase data sharing, facilitate care coordination, and split the value of savings across stakeholders. ACO programs for Medicare include the Medicare Shared Savings Program (MSSP) and Next Generation ACO Model (NGACO).
Medical Home is a model of care focused on increasing patient access and delivering comprehensive primary care to patients. Often nestled inside an ACO, this model ensures that patients have access to a care team led by their personal physician. This care team provides comprehensive services across acute, chronic, preventive, and end-of-life care. The care team also coordinates care for patients with providers in their community. Practices engaged in this model use quality and outcomes measures to track performance and improve care. Medicare’s new Comprehensive Primary Care Plus (CPC+) initiative follows the medical home model.
Bundled Payments are a reimbursement model aimed at improving coordination and quality across providers during a single episode of care or course of treatment. Instead of paying hospitals, physicians, and additional healthcare providers separately for services, bundled payments set a single price for all related care. For example, a bundled payment for a knee replacement may cover the cost of the procedure, anesthesia, physician services, and any post-acute care during the recovery period. Under this model, providers are directly incentivized to manage the cost of services and coordinate care to improve patient outcomes. Medicare’s bundled payment programs include the Bundled Payments for Care Improvement (BPCI) initiative and the Comprehensive Care for Joint Replacement (CJR) model.
The Medicare Value Based Care Landscape
Introduction to Alternative Payment Models
Alternative Payment Models (APMs) are programs designed to shift traditional, fee-for-service payments to value based care models. The Centers for Medicare and Medicaid Services (CMS) offers several APMs to transform reimbursement for Medicare and Medicaid patients.
Your practice may be eligible to participate in one or several of these models:
Medicare Shared Savings Program (MSSP)
MSSP is the largest ACO program in the country, with 480 enrolled ACOs covering a combined 9 million patients across all 50 states, Washington, D.C., and Puerto Rico. MSSP programs include a wide variety of providers, including networks of independent physician practices, group practices, hospitals, and federally qualified health centers. MSSP participants can apply to one of three payment tracks, sharing in savings and/or losses of their patients’ healthcare costs. Track 1 is the most common track and focuses only on shared savings (up to 50% of savings goes to providers). Tracks 2 and 3 include two-sided risk, requiring providers to share in both savings and losses (if patient costs increase). MSSP launched in 2012 and continues to accept applications for new participants each year. Learn more about Aledade’s MSSP ACOs.
Next Generation ACO (NGACO)
NCACO is a new program focused on existing ACOs with experience coordinating care for patient populations. The program’s two-sided risk model expands on MSSP by allowing providers to take on higher levels of financial risk and reward, including some capitation. Launched in 2016, the NGACO program currently includes 44 ACOs and lasts three years, with possible extensions to 2020.
Comprehensive Primary Care Plus (CPC+)
CPC+ is a two-track program focused on extending the medical home model across a large set of primary care practices. The program will pay physicians a monthly care management fee to provide a wider set of primary care services and better coordinate care for their patients. Additional changes include performance-based incentives and a hybrid payment system that mixes fee-for-service with capitation payments (for Track 2 only). The program will include Medicare, state Medicaid programs, and commercial insurance plans across 14 regions. CPC+ began in January 2017 and will last five years. Note: practices can participate in both CPC+ and MSSP
Bundled Payments for Care Improvement Initiative (BPCI)
BPCI is an extensive bundled payment program that currently includes over 1,300 participating organizations throughout the country. The initiative includes four separate models of bundled payments that vary in the coverage of treatments, scope of services, duration of episode, and payment method. Model 1 covers the inpatient component of all Medicare diagnosis related groups (MS-DRGs), while Models 2,3, and 4 cover a broader set of services for a subset of procedures (e.g., knee replacements). The program launched in 2013 and will extend to 2018 for a subset of existing participants.
Additional Value Based Care Programs
In addition to the programs listed above, Medicare offers a variety of value based care programs for targeted patient populations, including: Comprehensive ESRD Care (CEC), Million Hearts: Cardiovascular Risk Reduction Model (MH), and the Oncology Care Model (OCM).
The Commercial Value Based Care Landscape
Broadening Your Efforts
All patients deserve the best value for their care regardless of their insurance. Commercial insurance plans offer a wide variety of incentive, shared savings and even risk-based programs aimed at value based care, including Commercial ACOs and Medical Home programs. By understanding the existing options and working with your local insurers to create new programs, your practice can share in the value you create and receive access to the data necessary to provide the best care coordination possible for all your patients.
Navigating Value Based Care Programs
Based on your location, patient population, and EHR technology, your practice may be eligible to participate in one or more of the APMs and Commercial programs mentioned above. Aledade recommends that all physician practices seek a navigational partner to help in the transition to value based care.
Is Your Practice Interested in Learning More?
If you’re interested in learning more about how Aledade can help your practice navigate the new healthcare economy, please complete the form below. We will provide you a free, customized opportunity analysis to help you understand the benefits of joining an Aledade ACO.