Presentation on theme: "Accountable Care Organizations Opportunities for Patient Advocates Presented by Diane Soule Professional Patient Advocate Institute."— Presentation transcript:
Accountable Care Organizations Opportunities for Patient Advocates Presented by Diane Soule email@example.com Professional Patient Advocate Institute I Networking Call February 4, 2013 firstname.lastname@example.org
New Care Models ACO Medical Home How can you find opportunity as a Patient Advocate?
ACO Accountable Care Organization Medicare Shared Savings Program (MSSP) Commercial NCQA or other certification CMS Definition - What's an ACO? Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. CMS - http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/ACO/index.html?redirect=/aco/ 4
PCMH Patient-Centered Medical Home NCQA Accreditation AAAHC - Accreditation Association for Ambulatory Health Care NCQA Definition – What is a PCMH? A health care setting that facilitates partnerships between individual patients and their personal clinicians, and when appropriate, the patients’ family. Care is facilitated by registries, IT, exchange of health information and other means to ensure that patients get the indicated care, when and where they need and want it, in a culturally and linguistically appropriate manner. NCQA - PCMHhttp://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHom ePCMH.aspx 5
Regulatory Impact on Care Models CMS Regulations NCQA programs Technology Standards (HL7, Meaningful Use) 6
How Patients are Assigned ACO – MSSP – assigned by CMS in groups of 5000 beneficiaries ACO Commercial – Decision made to act as an ACO and/or obtain accreditation by NCQA PCMH – a medical group practice and all of its patients 7
ACO Compliance Top Ten 1.Compliance Officer 2.Mechanisms for Identifying and Addressing Concerns Escalation and Monitoring Procedures 3.Mechanisms for Anonymous Reporting Hotlines 4.Effective Training 5.Mechanisms for Reporting Violations to Law Enforcement 6.Policies and Procedures 7.Functioning Compliance Committee 8.Finalized & Distributed Compliance Plan 9.Notification and Opt-Out Procedures Complete Mail Out Procedures In Office Requirements 10.OIG Screening Procedures 8 Can you help with any of these areas? Look for ways to help an ACO comply with regulations and improve patient health.
Patient Engagement & Patient Experience Where can Patient Advocates Fit in?
Objectives ■To launch, activate and grow ACO partnerships through successful engagement of patient and providers stakeholders. ■To create and implement marketing programs that help ACOs achieve the 3-part objectives established by the Medicare Shared Savings Program which are central to our mission. o Better Care o Improved Health o Lower Cost 10
Patient Advocates Innovation Projects Embedded Care Coordinators Share among smaller practices Full time in offices/hospitals/health plans Be creative and develop an “Innovation” project http://www.accountablecarefacts.org/topten/wha t-is-an-accountable-care-organization-aco-1 http://www.accountablecarefacts.org/topten/wha t-is-an-accountable-care-organization-aco-1 11
Care Coordination Update Opt In Opt out Transitions in Care Embedded CC Inpatient CC/DC planning
ACO Overview The Centers for Medicare & Medicaid Services (CMS) auto-assigns Medicare patients to the Accountable Care Organization (ACO) based on history of care. CMS requires each ACO to provide all associated patients with an opportunity to opt-out of claims data sharing. ACOs are also required to provide a Drug and Alcohol release form to the beneficiaries to receive this data. 13
Opt Out Overview Advocate Opportunity Upon their first visit to a participating provider, ACO patients must be presented with the opportunity to opt-out of data-sharing. Some patients may elect to opt-out of sharing their personal health information. Patients have the opportunity to reverse their decision and opt back into the data sharing process at any time. Patient Advocates should find ways to be a part of this process. 14
Revenue Opportunities From medical group practices From hospital models As a Patient Experience consultant Create innovation project Innovation Centers through CMS and AHQR for funding opportunities http://www.innovations.ahrq.gov/funding- opportunities.aspx http://innovation.cms.gov/ 15
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