EMHS was selected as one of 32 ACOs under the Center for Medicare and Medicaid Innovation Pioneer ACO initiative,14 which started in January 2012. Under this five-year arrangement with CMS the EMHS ACO bills Medicare under existing fee-for-service (FFS) rules for their attributed patients during the first two years of the project and then transitions into capitated payment in year 3 of the pilot. The ACO shares Medicare savings in year 1 and then move to a shared savings/shared loss mode in year 2. In year 3 the Pioneer ACOs will chose a portion of the Medicare spend for per member per month payment, and continue with shared savings/losses for the remaining Medicare revenue. Throughout the pilot shared savings are based upon financial performance and 33 quality measures reported to CMS.
1st Performance Year: Report 33 measures to receive up to 50% or 60% (depending on their model) of Medicare shavings.
2nd Performance Year: Report eight measures and paid for performance on 25 measures.
3rd Performance Year: Pay for performance on 32 measures and pay for reporting on one survey measure related to functional status.
The 33 quality measures used to assess performance have been endorsed by the National Quality Forum (NQF) and reported across all 32 Pioneer ACOs. Attachment J-1 provides a detailed list of measures, NQF measure ID, method of submission and reporting or performance requirement. The following list summarizes the primary domains that the 33 measures fall under:
Patient/Caregiver Experience such as timely appointments, education, access to specialists. There are seven measures in this domain that are submitted via a survey.
Care Coordination/Patient Safety such as medication reconciliation after discharge from an inpatient facility, hospital readmissions, falls screening. There are six measures in this domain that are submitted by EHR Incentive Program Reporting or a special web interface.
Preventive Health such as influenza immunizations, pneumococcal vaccination, certain screenings. There are eight measures in this domain submitted through the GPRO web interface.
At-Risk Populations (Diabetes, Hypertension, Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease) such as specific clinical measures. There are 12 measures in this domain all submitted through the GPRO web interface.
The EMHS ACO has begun to look at home care pathways based on disease process and how to integrate community services and supports for non-homebound patients (such as the CHF telehealth program described above). They are also evaluating the value added contribution of the CCTs (related to PCMH), home care and hospice to the ACO. EMHC reports that for every dollar invested in home care during the first year of the pilot, they save $3 as an ACO.
EMHS utilizes a system called Arcadia to manage and report quality measurement data. The ACO quality measure data is pulled into the Arcadia system through direct interface from either the EHR or other import mechanism. All provider organizations that are part of the ACO are required to collect and report quality measure data. For those organizations that are not part of the EMHS technical infrastructure are required to report quality measures in a spreadsheet format for importing. Arcadia is also used for other quality reporting processes including Meaningful Use (MU) required reporting.
14. CMS Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions. See http://innovation.cms.gov/Files/x/Pioneer-ACO-Model-Frequently-Asked-Questions-doc.pdf.
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