Accountable care organizations Why They Matter Even More than Ever

JULY 23, 2018 RALEIGH, NORTH CAROLINA OLD NORTH STATE MEDICAL SOCIETY 2018 ANNUAL MEETING JULY 23, 2018 RALEIGH, NORTH CAROLINA

Private Rural family physician KAREN L. SMITH, MD, FAAFP 929 WEST PROSPECT AVENUE RAEFORD, NC 28376 WWW.KARENSMITHMD.COM Private Rural family physician

LEARNING OBJECTIVES 1. REVIEW THE ACO/CIN CONCEPT 2. DISCUSS BEST ACO FEATURES 3. REVIEW EXPECTATIONS OF PARTICIAPANTS 4. REVIEW EXPECTATIONS OF THE ACO 5. REVIEW ACO LOOK ALIKES

ACO PURPOSE AND FUNCTION Provision of collaborative and accountable care systems desired physician led team approach patient centered care standardization of evidence based best practices community based care coordination investment in health information technology participate in reimbursement incentives for quality and efficient care

POTENTIAL BENEFITS OF ACO PARTICIPATION Collaboration with hospitals and payors to promote continuity of care participation on public payor programs such as mssp participation in private/public multiple payor intiatives collaboration with other aco participants with similar GOALS

OBLIGATION OF THE ACO Support and coordinate the activities of the aco participant for joint accountability for improving quality of care and reduction in spending collect claims and clinical data in aco central data repository insure every patient in the aco has a primary care provider who assumes responsibility for the care develop and provide training in support programs which incorporate evidence-based practice standards of care

OBLIGATION OF THE ACO ESTABLISH CLINICALLY VALID AND SEVERITY-ADJUSTED PERFORMANCE METRICS, MONITOR PREFORMANCE MEASURES, PROVIDE REGULAR FEEDBACK, WITH PERIODIC REPORTS PROVIDE TOOLS AND INITIATIVES TO FACILITATE CARE TRANSITIONING INVOLVEMENT IN CONTRACTUAL COMMUNICATIONS WITH PAYORS IF REQUESTED AND PERMITTED PROVIDE ADMINISTRATIVE SUPPORT WITH FINANCIAL ACCOUNTING, ADMINISTRATION, WITH OPERATION IN A FINANCIALLY SOUND AND PRUDENT MANNER

OBLIGATION OF THE ACO PARTICIPANT Maintain personnel and facilities to meet responsibility under the agreement maintain all licenses, qualifications, certifications, and privileges maintain proper enrollment in payor programs insure policies and procedures are in compliance with aco policy and procedures provide care coordination services for aco patient panel participate with contracted services in good faith provide relevant data for care and management of patients

OBLIGATION OF ACO PARTICIPANT MAINTAIN UPDATED LIST OF PARTICIPATING PROVIDERS AND AFFILIATION INCLUDING EMPLOYMENT STATUS AND TIN MAINTAIN ELECTRONIC HEALTH RECORD SYSTEM INSURE PARTICIPATING PROVIDERS DO NOT AVOID HIGH RISK PATIENTS PROVIDE SERVICE ON ACO COMMITTEES UPDATE BUSINESS ASSOCIATES AGREEMENT

PREVENTION OF FATAL FLAWS PARTICIPATE in a alternative payment model research the historical performance of the aco REVIEW THE ORGANIZATION STRUCTURE AND INSURE KEY PLAYERS INSURE ABILITY FOR MEANINGFUL INVOLVEMENT WITH GOVERNANCE STRUCTURE REVIEW TERMS AND OBLIGATIONS OF ALL PUBLIC AND PRIVATE PAYOR CONTRACTS UNDER CONSIDERATION BY THE ACO INSURE AVAILABILITY OF OPT OUT RIGHTS

PREVENTION OF FATAL FLAWS 7. REVIEW TO INSURE LEGAL COMPLIANCE FOR STATE AND FEDERAL STATUTES 8. UNDERSTAND COMPENSATION STRUCTURE AS WELL AS PAYMENT PAYMENT REQUIREMENTS FOR PARTICIPATION 9. CLARIFY IF ANY PORTION OF COMPENSATION IS SUBJECT TO ACO LOAN OBLIGATION PRIOR TO FUND DISBURSEMENT 10. UNDERSTAND TERM LIMITS 11. KNOW TERMINATION RIGHTS AND IMPACT ON PERFORMANCE AND REPORTING TIMELINES WITH PAYORS

BENEFITS OUTWEIGH THE RISK? ECONOMY OF SCALE IS APPLIED TO POPULATION BASED HEALTH INITIATIVES FOR QUALITY AND COST DECREASED BURDEN ON THE SOLO OR SMALL OR RURAL OR HPSA CLINICIANS QUALIFICATION FOR MINIMIZING NEGATIVE PAYMENT RISK ADJUSTMENTS IMPROVE POTENTIAL FOR PAYOR CONTRACTS DUE TO LARGER PATIENT COHORTS/PANEL SIZE

ACO LOOK ALIKES CLINICALLY INTEGRATED NETWORKS STRUCTURAL ORGANIZATION IS TYPICALLY THE SAME ALLOWS REGIONAL PARTICIPATION WITH HOSPITAL AND OTHER HEALTHCARE ENTITIES WITH PRACTICES BOTH SMALL AND LARGE MULTI-SPECIALTY COLLABORATIVES ALLOWING SHARED DATA FOR COMMON PATIENT POPULATION CENTRALIZED DATA REPOSITORY FOR QUALITY AND COST MEASURES SHARED JOINT DECISION MAKING WITH SUGGESTED PROTOCOLS FOR IMPROVEMENT INTIATIVES

EXPERIENCE WITH CIN PROVIDE OPPORTUNITY FOR COLLABORATION WITH REGIONAL BASED PROVIDERS INSIGHTS AND PRESPECTIVES FROM PRIMARY CARE AND SPECIALISTS AND HOSPITAL REPRESENTATIVES MINIMAL DIRECT FINANCIAL RISKS BUT NO GAINS TIME INVESTMENT REQUIRED ACCESS TO DATA TYPICALLY NOT AVAILABLE IN PRIVATE ELECTRONIC HEALTH RECORD DATA TRANSPARENCY

SHARE YOUR EXPERIENCE 1. CURRENT OR PAST PARTICIPATION 2. “ACO READINESS” 3. INCLUSION/EXCLUSION ISSUES 4. FINANCIAL PERMISSIVENESS 5. HIGH RISK POPULATION/SODH ISSUES

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