Factors ACOs Must Consider as They Transition from CMS’s Medicare Shared Savings Program to Pathways to Success

Factors ACOs Must Consider as They Transition from CMS’s Medicare Shared Savings Program to Pathways to Success

ACOs have big decisions to make regarding CMS’s Pathways to Success value-based initiative. With new rules dictating how long they can stay in the Shared Savings track before moving towards a risk arrangement, eligible ACOs must now determine:

  • Which Pathways track is right for their organization
  • When to enter that track
  • How to adjust their operations to hedge against downside risk

Dr. Sanjay Seth, Chief Medical Informatics Officer at HealthEC and Cliff Frank, Interim Executive Director at Shore Quality Partners, highlighted a number of factors that ACOs must consider during their recent ACO Exhibit Hall webcast “How to Determine Your ACO’s Readiness to Move Toward Risk.” Here are the highlights of their webinar.

Which ACO Performance Track Should be Selected?

There are nine aspects to consider when selecting an ACO performance track. These include:

  • Track options
  • Risk level
  • Entry point
  • Experienced vs inexperienced provider group
  • Low or high revenue organization
  • Benchmark changes
  • Assignment changes
  • Attribution methodology changes
  • Agreement length

Additionally, it is important to understand critical differences between new and existing regulations. Significant changes have been made in several areas including attribution methodology, level of risk, telehealth, member notification, beneficiary incentives, benchmarks, and funding.

Is Staffing In Line with Downside Risk?

  • Determine where more staffing capabilities may be needed to support new efforts in the arena of downside risk. This may include partnering with other care organizations to initiate and support additional programs.
  • Use a data platform at the central office to support provider site efficiency improvements.
  • Engage physician leadership and ACO administrative leadership in more active discussions. (Data transparency will be central to this.)

Are Physicians Prepared for a New Business Model?

Physician culture, including the ability or willingness of physicians involved in taking financial risk to drive change, plays a tremendous role in achieving success. Hard conversations typically avoided due to fear of provider project abandonment will be necessary. We highlighted five components of an effective physician engagement strategy during our webinar.

  • Driving down patient leakage
  • Focusing referrals to high-performing specialists
  • Consistently meeting the basics of patient wellness, prevention, immunizations, annual visits, follow-ups, transitions of care visits and medication reconciliation
  • Keeping patient engagement at a fundamental level, including working in Medicare patients to keep small issues small
  • Taking direct, limited financial risk

Is Funding Available to Cover a Possible Payment to Medicare?

When taking on downside risk, a pivotal factor for ACOs is preparing for the eventuality or potential that the organization has to write a check back to Medicare. In anticipation of a payment scenario, ACOs must came up with sources to make funds available. Several funding options can help ACOs meet this need when participating in a downside risk model, including:

  • PCP membership fees
  • Net collections from reinsurance
  • MA star bonus program
  • Previous year bonus carryover
  • Bonus deductions
  • Hospital/investor line of credit

To learn more about how HealthEC can help your ACO with population health management solutions and advisory services, contact us today!