Yesterday, the American Health Care Association and the National Center for Assisted Living plus the National Assocation of ACOs released a white paper that includes a set of recommendations for CMS, designed to increase the participation of long term and post-acute care (LTPAC) providers in accountable care organizations (ACOs). The white paper is available here: AHCA NAACOS White Paper_Final_240222_111242
CMS has a goal of getting all Medicare beneficiaries involved in an ACO at some level, by 2030. Today, less than 2,000 SNFs participate in an ACO and fully 70% of all ACOs have no SNF engagement at all. Per the release, “current program policies in ACO models do not align well with LTPAC providers, including those that determine which patients ACOs are accountable for, setting financial benchmarks, and quality measures. But as one of the highest-cost and most complex patient populations, LTPAC presents a significant opportunity for improved resident outcomes and reduced costs to the Medicare program.”
The concept of an ACO at the core is a shared savings approach or more simplistically, a global payment program whereby, providers that participate within the ACO, are incentivized to become more efficient in care delivery and more effective in the care provided (improved outcomes). Assumptively, care provided that is more cost-effective and in turn, produces a better outcome, creates savings. The savings are then available to the ACO members as a “bonus”. As post-acute providers are typically, less expensive for certain kinds of care, opportunities exist to leverage these cost efficiencies in ACO models.
Post acute care has played an important role in the success of value-based care models, with significant savings and care improvements in ACO and episodic payment models generated by the post-acute care partnerships. In a review of 21 CMS Innovation Center models, 14 models (or 66 percent) had reductions in spending driven by post-acute care utilization.
One of the largest stumbling blocks in achieving greater post-acute participation in ACOs is the financial considerations which, generate payments on a direct and shared basis. Participating in a value-based care model requires accurate benchmarking, risk adjustments, and quality measures. Financial benchmarks, the spending targets for models, are currently sensitized by historical spending. Under current policy, the benchmarks are not likely appropriate for the long
term nursing home/assisted living population, as the historic data understates the actual cost of care in the facility. Risk adjustment models are also likely to under predict SNF patient costs for similar reasons.
In terms of quality, the number one issue that requires increased emphasis and definitional clarity is around care coordination and the opportunity to avoid unnecessary transitions, typically to higher levels of care. Historically, this challenge can only be overcome by participants being willing to practice across settings. Today, physician care for example, is more compartmentalized than ever. Intensivists don’t migrate between care settings and primary care physicians by virtue of current payment models, rarely see patients outside of an office or clinic setting. This fragmentation significantly contributes to care redundancy (repetition of tests), polypharmacy, and unnecessary care transitions (hospitalizations, ED transfers, rehospitalizations).
Another significant challenge for post-acute expansion in ACOs is information system interoperability. Few post-acute software systems have integration with hospital systems. Data set definitions, cross providers, don’t really exist. Full interoperability such that each provider can freely exchange data, review medical record information including medication lists, treatments, diagnostics, etc., does not yet, exist, even among affiliated providers in a health system. Again, this gap produces delays in care, repetition of care, polypharmacy, unnecessary care transitions, etc. Solving this issue is far from inexpensive and would require a funding commitment from the ACO partners.
The report concludes that opportunities exist for CMS to more meaningfully engage SNF providers in broader delivery system transformation efforts via adjustments to existing accountable care arrangements. Additional development of future models should include the needs of SNF populations as part of the process. More accountable care development and integration of provider types should provide SNF residents with improved care coordination, and more efficient, patient-centered care.
This past fall, November, I wrote a post on value-based care models that provides additional information on various models including Accountable Care Organizations, Bundled Payment Plans, etc. The post is here: https://rhislop3.com/2023/11/28/value-based-care-what-it-is-and-how-it-can-work-for-post-acute-providers/
Readers that want more information on interoperability and the HITECH Act (data sharing between providers), a post I did on that subject is available here: https://rhislop3.com/2018/06/27/interoperability-and-post-acute-implications/
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