MSSP ACOs Have Below Average Quality Results

Last week we reported the CMS announcement on ACO success—savings of $372 million and $445 million paid in bonuses. But a new report from Avalere Health notes that quality results are not keeping pace with cost reductions. It’s a prime example of ACO payment complexity.

 

Medicare Shared Savings Program (MSSP) ACOs were not required to meet quality measure benchmarks to share in savings during their first performance year. And, in fact, 59 percent of the participants that earned savings bonuses for 2013 had below average quality scores. The only ACO that had to repay CMS achieved better that average quality. (“Majority of ACOs with Shared Savings Scored Below Average on Quality Measures, Report Finds,” Health Lawyers Weekly, September 27, 2014)

 

But to put this in perspective, ACOs that earned bonuses generally outperformed the others on 15 measures, including screening patients for risk of falls and reconciling medication for patients who leave the hospital.

 

Those that failed to earn bonuses, however, did better on a few measures, including timely access to care and the percentage of doctors who met the federal criteria for the meaningful use of electronic health records. (“For their first year, ACOs see varied scores in quality measures,”Modern Healthcare A.M., September 29, 2014)

 

“These ACO results reveal a potential disconnect between achieving high-quality care as indicated by the ACO quality measures and the ability to achieve savings,” an Avalere Health executive, said. (Avalere Analysis, Most Medicare ACOs Earning Shared Savings Payments Were Below Average on Quality, Avalere Health, September 25, 2014)

 

Overall, the 220 ACOs that completed their first MSSP performance year in 2013 earned on average three-quarters of possible quality points, according to the report. However, “this average skews upward as fewer than two in five ACOs had better than average quality scores.” (Avalere Analysis, Most Medicare ACOs Earning Shared Savings Payments Were Below Average on Quality, Avalere Health, September 25, 2014)

 

Some specific results noted in the Avalere report include:

 

  • The top five quality measures by percent of ACOs earning maximum points:
    • Doctor Communication
    • Doctor Rating
    • All Condition Readmissions
    • Tobacco Use Assessment
    • Medication Reconciliation

 

  • The bottom five quality measures by percent of ACOs not earning points:
    • Avoidable Heart Failure Admissions
    • Avoidable COPD/Asthma Admissions
    • Diabetes Composite
    • Coronary Artery Disease Composite
    • Screening for Risk of Falls

 

After the first performance year, CMS will reduce shared savings payments to ACOs that don’t meet maximum quality benchmarks. ACOs that fall below minimum quality benchmarks will not share in savings at all.

 

For the full report from Avalere Health, please contact Carlin Lockee at clockee@iprotean.com.

 

 

 

 

iProtean subscribers, Physicians and the New Healthcare Business Model is in your library. Featuring Todd Sagin, M.D., J.D. and Larry McEvoy, M.D., this course takes an in-depth look at the physician perspective of the new healthcare business model, and offers suggestions to boards on how to work with physicians to accomplish a successful transition to this model.

 

Our next advanced course, due in your library at the end of October, features noted governance experts Barry Bader and Pam Knecht.

 

 

For a complete list of iProtean courses, click here.

 

For more information about iProtean, click here.

 

CMS Reports on Pioneer and MSSP ACOs

Pioneer accountable care organizations (ACOs) and Medicare Shared Savings Program (MSSP) ACOs have saved $372 million to date and provided participants $445 million in bonuses, the Centers for Medicare and Medicaid (CMS) reported this week.

 

The results came from preliminary quality and financial results from the second year of 23 pioneer ACOs, and from the first year of 220 MSSP ACOs. Sixty-four (64) ACOs earned a total of $445 million in bonuses for their efforts to reduce the costs of care while improving clinical outcomes for Medicare beneficiaries enrolled in them. (“ACOs Save Medicare $372 Million,” HFMA Weekly News, September 19, 2014)

 

A Health and Human Services Fact Sheet reported the following:

 

 

Pioneer ACO Performance Year 2 Results

Pioneer ACOs showed improvements in three key areas: financial, quality of care, and patient experience.

 

Financial:

  • During the second performance year, Pioneer ACOs generated estimated total model savings of over $96 million and at the same time qualified for shared savings payments of $68 million. They saved the Medicare Trust Fund approximately $41 million. The total model savings and other financial results are subject to revision.
  • Pioneer ACOs achieved lower per capita growth in spending for the Medicare program at 1.4 percent, which is about 0.45 percent lower than Medicare fee-for-service.
  • Eleven Pioneer ACOs earned shared savings, 3 generated shared losses, and 3 elected to defer reconciliation until after the completion of performance year three.

Quality of Care and Patient Experience:

  • The mean quality score among Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2 percent in 2013.
  • The organizations showed improvements in 28 of the 33 quality measures and experienced average improvements of 14.8 percent across all quality measures. These measures included screening for future fall risk, screening for tobacco use and cessation, patient experience in health promotion and education, and controlling high blood pressure.
  • The Pioneer ACOs improved the average performance score for patient and caregiver experience in 6 out of 7 measures. These results suggest that Medicare beneficiaries who obtain care from a provider participating in Pioneer ACOs report a positive patient and caregiver experience.

 

Medicare Shared Savings Program Performance Year 1 Results

  • 53 Shared Savings Program ACOs held spending $652 million below their targets and earned performance payments of more than $300 million as their share of program savings. One ACO in Track 2 overspent its target by $10 million and owed shared losses of $4 million.  The Medicare Trust Funds will save about $345 million, including repayment of losses for one Track 2 ACO.
  • An additional 52 ACOs reduced health costs compared to their benchmark, but did not qualify for shared savings, as they did not meet the minimum savings threshold.
  • Shared Savings Program ACOs improved on 30 of 33 quality measures. Quality improvement was shown in such measures as patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctor, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure.
  • Shared Savings Program ACOs achieved higher average performance rates on 17 of the 22 Group Practice Reporting Option Web Interface measures reported by other Medicare FFS providers reporting through this system.
  • In 2013 alone, over 125,000 eligible professionals who were ACO providers or suppliers qualified for their incentive payments for reporting their quality of care through the Physician Quality Reporting System (PQRS) These providers will also avoid the PQRS payment adjustment in 2015 because they demonstrated the ability to report quality measures through their ACO.

 

“In addition to the savings attributed to these new payment models, quality and patient experience scores improved as well,” said a Healthcare Financial Management Association executive. “These results demonstrate the commitment of these participants to greater collaboration with each other in a number of areas, as well as a continued focus on keeping patients healthy rather than treating them when they were sick.” (“ACOs Save Medicare $372 Million,” HFMA Weekly News, September 19, 2014)

 

 

Read the CMS press release here.

 

 

 

iProtean subscribers, Physicians and the New Healthcare Business Model is in your library. Featuring Todd Sagin, M.D., J.D. and Larry McEvoy, M.D., this course takes an in-depth look at the physician perspective of the new healthcare business model, and offers suggestions to boards on how to work with physicians to accomplish a successful transition to this model.

 

Our next advanced course, due in your library at the end of October, features noted governance experts Barry Bader and Pam Knecht.

 

 

iProtean subscribers, Physicians and the New Healthcare Business Model is in your library. Featuring Todd Sagin, M.D., J.D. and Larry McEvoy, M.D., this course takes an in-depth look at the physician perspective of the new healthcare business model, and offers suggestions to boards on how to work with physicians to accomplish a successful transition to this model.

 

Our next advanced course, due in your library at the end of October, features noted governance experts Barry Bader and Pam Knecht.

 

 

 

For a complete list of iProtean courses, click here.

 

For more information about iProtean, click here.

 

Researchers Report on ED Use Post-ACA Implementation

Two recent studies on emergency departments (ED) show two sides to patients’ use of the ED.

 

Researchers from the Colorado Hospital Association (CHA) reported that Medicaid enrollees added under healthcare reform are both sicker and increasing their use of hospital EDs. The national analysis is based on data from 450 hospitals in 25 states, 13 of which expanded and 12 of which did not.

 

Health Affairs reported that the healthcare reform provision that allowed young adults to stay on their parents’ insurance plans longer might have slowed the ongoing increase in their use of hospital EDs.

 

New Medicaid Enrollees and ED Use

 

Researchers have been reporting that states that expanded Medicaid as authorized by the Affordable Care Act (ACA) have increased their share of Medicaid patients and reduced their share of self-pay patients. Experts have predicted that the new Medicaid enrollees would be healthier than traditionally eligible Medicaid enrollees. The new research from CHA doesn’t match these predictions.

 

An examination of the relative health of the new Medicaid enrollees was conducted in an in-depth, Colorado-specific portion of the study. The research shows a 10 percent increase in the case mix index (a measure of complexity and resource needs) in the first quarter of 2014 compared to the first quarter of 2013.

 

ED usage increased 5.6 percent among expansion state hospitals in the second quarter of 2014 compared to a 1.8 percent increase in non-expansion states.

(“New Medicaid Enrollees Sicker, Increasing ED Use,” HFMA Weekly News, September 12, 2014)

 

Young Adults and ED Use

 

The Health Affairs study compared ED use by young adults before and after a September 2010 provision of ACA went into effect. This provision allowed people through age 25 to stay on their parents’ insurance. Under this provision, the ongoing increase of these young adults’ use of hospital EDs has slowed.

 

According to the study’s authors, there was a reduced increase in ED use by this cohort of 2.1 percent, or 99,178 fewer ED visits in the three largest states examined (California, Florida and New York) than would otherwise have occurred.

The authors speculated that the increased insurance coverage could have encouraged better access to healthcare in non-ED settings, such as physician’s offices, which potentially would have reduced the use of ED care by the young adults.

 

However, the authors “stopped short of saying their findings confirmed a link between the ACA provision and the resulting ED use.” (“Study: ACA Coverage May Have Curbed ED Use Among Young Adults,” HFMA Weekly News, September 12, 2014)

 

 

 

iProtean subscribers, Physicians and the New Healthcare Business Model is in your library. Featuring Todd Sagin, M.D., J.D. and Larry McEvoy, M.D., this course takes an in-depth look at the physician perspective of the new healthcare business model, and offers suggestions to boards on how to work with physicians to accomplish a successful transition to this model.

 

Our next advanced course, due in your library at the end of October, features noted governance experts Barry Bader and Pam Knecht.

 

 

For a complete list of iProtean courses, click here.

 

For more information about iProtean, click here.

 

Hospitals Can Get Partial Payment for Medicare Appeals

When hospitals appeal a claim denial by CMS, the wait time for a decision currently averages 489 days compared to the 90 days required by law. Both the American Hospital Association and the Center for Medicare Advocacy have filed lawsuits to compel the Secretary of Health and Human Services to meet statutory deadlines for reviewing the Medicare denials. CMS now is offering an administrative agreement to any acute care or critical access hospital that agrees to resolve its pending appeals (or waive its right to request an appeal) in exchange for a partial payment of 68 percent of the net payable amount.

 

A Medicare Learning Network eNews brief noted “CMS encourages hospitals with patient status claim denials currently in the appeals process to make use of this administrative agreement to alleviate the burden of current appeals on both the hospital and Medicare system.” (“CMS Offers Settlement to Acute Care Hospitals and CAHs to Resolve Appeals of Patient Status Denials,” MLS Connects Provider eNews, August 29, 2014)

 

The growing backlog of Medicare appeals has been the subject of recent congressional oversight and lawsuits. A CMS administrative law judge told lawmakers in July that the Office of Medicare Hearings and Appeals (OMHA) has experienced a 545 percent increase in appeals from 2011 to 2013. Late last year, OMHA suspended assignment of most new requests for hearings for at least two years because of the Medicare appeals backlog. (“CMS Offers Partial Payment to Hospitals to Lessen Medicare Appeals Backlog,” Health Lawyers Weekly, September 5, 2014)

 

 

 

iProtean subscribers, Physicians and the New Healthcare Business Model is in your library. Featuring Todd Sagin, M.D., J.D. and Larry McEvoy, M.D., this course takes an in-depth look at the physician perspective of the new healthcare business model, and offers suggestions to boards on how to work with physicians to accomplish a successful transition to this model.

 

Our next advanced course, due in your library at the end of October, features noted governance experts Barry Bader and Pam Knecht.

 

 

For a complete list of iProtean courses, click here.

 

For more information about iProtean, click here.

Hospital Revenue Growth Slows to Its Lowest Recorded Level

Historical revenue growth for not-for-profit hospitals has tended to hover around 7 percent annually, but in the last year, it dropped to 3.9 percent, the lowest level on record, according to a new report by Moody’s Investors Service.

 

Both a drop in hospital admissions (a first) and growth in expenses contributed to the decline. Expense growth exceeded revenue growth for the second year in a row.

 

Moody’s listed specific contributors to the income slowdown:

  • Increased use of high-deductible health plans, causing patients to postpone care or use lower-cost retail clinics
  • Deeper reimbursement cuts required by the 2012 Budget Control Act and the Affordable Care Act (ACA)
  • Medicare’s two-midnight rule