ACOs
Gregory C Burke
Berkeley ACO Forum
May 8, 2015
ACOs and Anti-Trust
• Aggregophobia (noun):
• Extreme or irrational fear of aggregations
• Particularly in the health care sector
• Schizophrenic Aggregophobia:
• We can’t decide whether we love it (IDS),
• Or hate it (restraint of trade and price-fixing)
• Either way, ACO’s per se aren’t the problem
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Providers need to aggregate to perform, as ACOs
But they’re aggregating, anyway, in FFS
Besides, accountable care isn’t about organizations, they’re Contracts
Not about increasing prices, but working against a budget
Managing against Total Costs of Care
2
Integrated Delivery Systems
Delivery
System
Primary
Specialty
Behavioral
Health
Urgent /
ED
Hospital
Post-Acute
LTC
“A network of organizations that provides or
a rra nges to provi de a coordinated continuum of
s ervi ces to a defined population a nd i s willing to
be held cl inically and fiscally accountable for the
outcomes a nd health status of the population
s erved.”
3
Integrated Delivery Systems
Delivery
System
Primary
Specialty
Behavioral
Health
Urgent /
ED
Hospital
Post-Acute
LTC
“A network of organizations that provides or
a rra nges to provi de a coordinated continuum of
s ervi ces to a defined population a nd i s willing to
be held cl inically and fiscally accountable for the
outcomes a nd health status of the population
s erved.”
S.M. Shortell, R.R. Gillies, and D.A. Anderson, et al.,
Remaking Health Care in America, San Francisco:Josey-Bass (1996) , p. 7.
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Organizational Types
Physician-Led
More
Integrated
Group Practice
Hospital System
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Less Integrated
Hospital-Led
Formally organized physician partnership
Unified leadership and aligned physicians
Common management, EMRs, and
systems
Infrastructure for contracting and quality
improvement
Number in New York: 5
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Unified leadership for system
Core of system-employed physicians
Common EMRs and other services
Infrastructure for contracting, data/analytics, and
quality improvement
Number in New York: 4
Physician Network
Physician-Hospital Partnership
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Independently practicing physicians
Most formed to contract with payers
Variable organization and infrastructure
Number in New York: 10
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Hospitals, physicians employed by hospital, and
independent physicians
Originally formed to contract with payers, now a
vehicle for clinical integration
Variable organization and infrastructure
Number in New York: 8
Shared Savings
6
Results of New York-based MSSP Participants in Performance Year-1
Total Benchmark
Expenditures Minus
Total Assigned
Beneficiary
Expenditures as % of
Total Benchmark
Total Assigned
Beneficiaries
Total Benchmark
Expenditures
Total Expenditures
Total Benchmark
Expenditures Minus Total
Assigned Beneficiary
Expenditures
Catholic Medical Partners-Accountable Care IPA, Inc.
33,253
$397,492,202
$369,569,629
$27,922,572
7.%
$13,682,060
ProHEALTH Accountable Care Medical Group, PLLC
28,651
$358,236,161
$336,322,174
$21,913,987
6.1%
$10,737,854
HHC ACO Inc
12,369
$107,675,574
$100,247,480
$7,428,094
6.9%
$3,639,766
ACO Name (LBN or DBA, if applicable)
Earned Shared Savings (N = 3)
$57,264,653
$28,059,680
Healthcare Provider ACO, Inc.
29,313
$498,653,673
$487,171,239
$11,482,434
2.3%
CCACO
13,833
$192,513,845
$189,064,665
$3,449,181
1.8%
Beacon Health Partners, LLP
16,790
$204,068,192
$201,059,123
$3,009,069
1.5%
Asian American Accountable Care Organization
14,769
$161,975,470
$160,113,015
$1,862,456
1.1%
Crystal Run Healthcare ACO, LLC
12,941
$208,622,533
$207,666,072
$956,461
.5%
Saved vs. Benchmark, but not shared savings (N = 5)
$20,759,601
Mount Sinai Care, LLC
25,042
$353,393,023
$354,901,324
($1,508,302)
WESTMED Medical Group, P.C.
14,082
$160,881,833
$162,429,210
($1,547,377)
-1.%
Accountable Care Coalition of Syracuse, LLC
14,057
$133,047,092
$135,514,524
($2,467,432)
-1.9%
Chautauqua Region Associated Medical Partners, LLC
7,884
$92,247,040
$95,229,434
($2,982,394)
-3.2%
Accountable Care Organization of the North Country, LLC
5,879
$69,726,454
$74,474,537
($4,748,083)
-6.8%
Accountable Care Coalition of Mount Kisco, LLC
16,326
$189,431,358
$200,210,762
($10,779,404)
-5.7%
Balance ACO
10,459
$208,786,843
$234,259,597
($25,472,755)
-12.2%
Did Not Save vs. Benchmark (N = 7)
Total Saved by 8 NYS ACOs with Savings vs. Benchmark
-.4%
($49,505,747)
$2,129,237,650
$2,051,213,397
$78,024,253
Source: https://data.cms.gov/ACO/Medicare-Shared-Savings-Program-Accountable-Care-O/yuq5-65xt
Earned Shared
Savings Payments /
Owe Losses3,4
3.8%
Accountable Care: Zero-Sum Game
Funded by Reductions in Hospital Income
Delivery
System
Primary
Specialty
Behavioral
Health
Urgent /
ED
New Infrastructure for
Population Health Management
Hospital
Post-Acute
LTC
Enhanced Capacities in Primary Care
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Avoided Hospital Admissions
A New Food-Source?
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The Next Target: Specialty Care Over-Use
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