Models of Care

The Medicare Shared Savings Program is a three year, renewable program that allows health care provider organizations (called “participants”) to earn a share of the savings achieved for a population of Medicare beneficiaries “attributed” to the participating providers (physicians or mid-level providers). Medicare attributes beneficiaries to ACOs based onhistorical billing information of the ACOs network participants by identifying the predominant primary care relationship for each Medicare beneficiary. The total cost of care for all attributed Medicare beneficiaries across all network participants in an ACO forms the basis for measurement and potential for earning shared savings.

For Ochsner Accountable Care Network participants who are a primary care physician, a primary care provider group practice, or an organization which employs primary care physicians, your patients that are Medicare beneficiaries will likely be attributed to OACN’s population of attributed Medicare beneficiaries. Although not as frequent, specialty physicians can also have Medicare beneficiaries from their practice attributed to OACN. Organizations that do not have primary care providers may still be network participants, contribute to the coordinated care of attributed beneficiaries and be eligible for shared savings within the ACO.

The Medicare Shared Savings Model

Ochsner Accountable Care Network participants will continue to treat all Medicare beneficiaries and bill Medicare for services as they do today, and will be paid under their normal Medicare fee-for-service reimbursement models. Medicare will establish an expected total cost of care target for OACN based on all historical Part A and Part B expenditures for the attributed Medicare beneficiaries. This target will include an increase factor for the national trend in Medicare expenditures. If the actual total cost of care rendered to the OACN-attributed Medicare beneficiaries is lower than the expected cost by more than the minimum savings threshold, the ACO earns shared savings from this difference. Ninety percent of any shared savings received by OACN will be distributed among the network participants. Ten percent will be used to partially offset expenses of OACN.

Please note that OACN has selected MSSP Track One with “upside only” potential.  This means you have no financial risk and will receive and keep the fee-for-service reimbursement you otherwise would for services performed and billed under the Medicare Fee-For-Service Program for the years 2013-2015. In “Track One,” upon meeting the minimum savings threshold and quality measures, OACN can receive up to 50% of the savings achieved against the target, and neither OACN nor its network participants pay any penalty whatsoever if we do not achieve our targeted performance. This is known as “upside only” or “shared savings only.” In the alternative “Track Two” model, an ACO becomes financially liable (within limits) if Medicare Fee-For-Service costs exceed a threshold set by Medicare. This is known as “Downside Risk”. Under current rules, an ACO that initially selects “Track One” is required to assume a “Downside Risk” track if the ACO re-enrolls for a subsequent three year period, which for Ochsner Accountable Care Network would be for 2016-2018. Neither Ochsner Accountable Care Network nor its individual network participants are obligated to re-enroll in the MSSP or continue participation in the Ochsner Accountable Care Network ACO beyond the initial three year period.

Quality Measurement and Performance Requirements

The MSSP has specified quality performance measures across four domains. Ochsner Accountable Care Network will need to collect and submit data that will be used to generate an overall quality score for OACN by Medicare. For year one of the MSSP, OACN will only need to submit a complete data set to qualify for full savings eligibility (“pay-for-reporting”). In subsequent years, OACN will need to meet a minimum performance threshold to be eligible for shared savings.

If this minimum is exceeded and Ochsner Accountable Care Network does achieve the cost target by more than the minimum savings rate, the actual shared savings amount will be adjusted byOACN’s overall quality score. Medicare intends to publish these exact parameters as the “pay-for-performance” period (year 2) approaches.

Other Program Elements

Although there are additional required elements in the MSSP for an ACO organization, most of the program details are left to an individual ACO to define. This includes network development and participation agreements, shared savings distribution models, and clinical improvement approaches.

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One Response to Models of Care

  1. gail kim says:

    Excellent article! We are linking to this particularly great article on our site.
    Keep up the great writing.

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