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Payers and Accountable Care Organizations

Opportunities for A Value-Added Delivery System

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Challenges for an ACO

Unknown patient population (aligned membership) and their underlying costs

No assigned membership- freedom to self-refer (Medicare fee-for-service)

Little or no formal process for directing patients through health care system or resource consumption

Requires lots of coaching by primary care practitioner (medical home and care coordinator role)

Must manage risk through care coordination, education and collaboration with partner providers for cost efficiency

Quality metrics requires disease-specific and individual case management

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Complementing ACO and Payer Delivery Systems

ACO Payer

Access to payer contracts and broadernetwork of care sites

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ACO and Payer Partnership

ACO Value Payer Value• Organized business entity with shared governance• Internal performance structure and oversight• Common goals established• Knowledge of delivery system and practice relationships• Adoption of practice protocols• Willingness to accept risk or shared-risk contracts• Basis for care collaboration and patient-centeredness• Ease in payer contracting

• Existing IT resources• Ability to provide:

Claims payment & data Population demographics Actuarial & underwriting support

• Medical cost management techniques On-site UM/case mgmt Pre-certification Alternative care settings

• Tracking and reporting outcomes data Performance feedback from data

• Access to broader health care delivery system (Payer’s contracts)• Access to payer’s clients and marketing

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Risk Management = Medical Management and Disease Management

Overall goal: provide best care at affordable cost in most appropriate setting

Adopt health plan-like utilization management practices:

– Pre-authorization– Concurrent review with Interqual® criteria– Discharge planning and follow up

Seek lower cost care settings Utilize network of providers under contract at

predetermined prices and conformance Adopt health plan-like disease management

programs for high risk and chronic care population:

CAD Diabetes Hypertension

COPD/emphysema CHF ESRD

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ACO and Payer Collaboration and Sharing of Clinical 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 across ACO delivery system (based on benchmark cost management goals and clinical outcomes)• Reporting/feedback on non-ACO (payer) network provider performance

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Coordination of Care and Patient Outreach Programs*

Establish clinical staff of care counselors Conduct welcome calls and introductions for

identified patient population Conduct risk assessment surveys from

prospective data and patient base Enroll targeted patients in disease

management and education programs Follow up with post-discharge patients

(inpatient and select outpatient procedures) Conduct periodic assessment and adherence

calls for high risk/chronic care patients Invest in home monitoring devices for at-risk

patients

* Shared role between payer and ACO

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IT Resource Needs*

Architecture of practitioner’s EMR/EHR system Capability to interconnect with other ACO

participants (e.g. specialists, hospitals, labs etc.)- providing results and care plan histories

Medical informatics (data mining) capability and technical help:

– For identifying and flagging high risk/at-risk patients from prospective data for targeted interventions

– Conducting cost (expenditure) trend analysis

Tracking referrals across ACO practices and outside the delivery system

Capability for secure internet patient contact and counseling

* Payer support role

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Contact Us

Eagle Run MCC has the expertise and capability to:• Construct and expand provider ACO networks for commercial and government requirements.

• Negotiate contracts on behalf of providers and the ACO entity and monitor contractual performance measures between providers and payers.

• Provide medical and patient management techniques to improve performance and produce desired clinical and cost outcomes.

• Provide access to low cost, leading-edge, cloud-based EMR, practice management and revenue cycle management services to increase productivity, profitability and health information exchange capability among provider practices and the ACO network.