aco and payer partnership- surviving health care reform

Download ACO and Payer Partnership- Surviving Health Care Reform

Post on 23-Jan-2015



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Health care reform initiatives offered through an ACO entity creates opportunities for both providers and payers to deliver affordable and high quality care for consumers. Each partner comes to the table with valuable resources to achieve common goals and outcomes.


  • 1. Payers and Accountable Care Organizations Opportunities for A Value-Added Delivery System1

2. Challenges for an ACO Unknown patient population (alignedmembership) and their underlying costs No assigned membership- freedom to self-refer (Medicare fee-for-service) Little or no formal process for directingpatients through health care system orresource consumption Requires lots of coaching by primary carepractitioner (medical home and carecoordinator role) Must manage risk through carecoordination, education and collaborationwith partner providers for cost efficiency Quality metrics requires disease-specificand individual case management2 3. Complementing ACO and PayerDelivery SystemsACOPayer Access to payer contracts and broader network of care sites3 4. ACO and Payer Partnership ACO Value Payer Value Organized business entity with Existing IT resources shared governance Ability to provide: Internal performance structure Claims payment & dataand oversight Population demographics Common goals established Actuarial & underwriting support Knowledge of delivery system Medical cost management techniquesand practice relationships On-site UM/case mgmt Adoption of practice protocols Pre-certification Willingness to accept risk or Alternative care settingsshared-risk contracts Tracking and reporting outcomes data Basis for care collaboration and Performance feedback from datapatient-centeredness Access to broader health care delivery Ease in payer contractingsystem (Payers contracts)4 Access to payers clients and marketing 5. Risk Management = Medical Managementand Disease Management Overall goal: provide best care at affordable costin most appropriate setting Adopt health plan-like utilization managementpractices: Pre-authorization Concurrent review with Interqual criteria Discharge planning and follow up Seek lower cost care settings Utilize network of providers under contract atpredetermined prices and conformance Adopt health plan-like disease managementprograms for high risk and chronic carepopulation: CAD COPD/emphysema Diabetes CHF Hypertension ESRD5 6. ACO and Payer Collaboration and Sharing ofClinical Data Utilizing paid claims data Identifying trends Focus on areas of improvement Consulting on care plans and alternatives Conducting patient experience surveys Evaluate quality and cost performance standards acrossACO delivery system (based on benchmark costmanagement goals and clinical outcomes) Reporting/feedback on non-ACO (payer) network providerperformance6 7. Coordination of Care and Patient OutreachPrograms* Establish clinical staff of care counselors Conduct welcome calls and introductions foridentified patient population Conduct risk assessment surveys fromprospective data and patient base Enroll targeted patients in diseasemanagement and education programs Follow up with post-discharge patients(inpatient and select outpatient procedures) Conduct periodic assessment and adherencecalls for high risk/chronic care patients Invest in home monitoring devices for at-riskpatients * Shared role between payer and ACO7 8. IT Resource Needs* Architecture of practitioners EMR/EHRsystem Capability to interconnect with other ACOparticipants (e.g. specialists, hospitals,labs etc.)- providing results and care planhistories Medical informatics (data mining) capabilityand technical help: For identifying and flagging highrisk/at-risk patients from prospectivedata for targeted interventions Conducting cost (expenditure) trendanalysis Tracking referrals across ACO practicesand outside the delivery system* Payer support role Capability for secure internet patientcontact and counseling8 9. Contact UsEagle Run MCC has the expertise and capability to: Construct and expand provider ACO networks for commercial andgovernment requirements. Negotiate contracts on behalf of providers and the ACO entity andmonitor contractual performance measures between providers andpayers. Provide medical and patient management techniques to improveperformance and produce desired clinical and cost outcomes. Provide access to low cost, leading-edge, cloud-based EMR, practicemanagement and revenue cycle management services to increaseproductivity, profitability and health information exchange capabilityamong provider practices and the ACO network.9


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