No one would disagree that better quality of service for less cost is highly desirable in any industry. It seems the Healthcare Delivery Industry has, for a long time, been “behind the times”.
Sparked by the incentives of the Affordable Care Act (ACA), a new and innovative approach to Healthcare Delivery, the Accountable Care Organization (ACO) has come into the forefront of patient care models. ACOs are groups of primary care physicians, specialists, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the patients they serve.
The basis of the ACO model can be represented with this acronym: PEACE
• Prevention of Illness and Disease
• Evidence-based Treatment
• Access to Care Resources
• Coordinated Medical Care Team
• Electronic Health Records
We can look at each of these points and explore the how and why the ACO model may provide a great start towards improving the Healthcare Delivery System in America.
Prevention of Illness and Disease - The best way to control health care costs is to stay healthy. Reducing readmissions and hospitalizations for preventable conditions alone could save the Medicare program at least $12 billion per year. It is estimated 50% of Americans don’t get the recommended preventive care and screening tests that science recommends.
ACOs believe in wellness and preventive care. You get reminders for the tests, screenings, and immunizations you need, and health information, classes, and advice are easily available.
Evidence-Based Treatment - Scientific advancements are so rapid that no single physician can stay on top of all the current and best treatment options. ACOs support their patients and doctors by providing information about up-to-date treatments based on research and evidence.
Access to Care Resources - Significant numbers of Americans don’t get the recommended health counseling and education for their conditions. Providing the right care at the right time is the goal of ACOs. Patients of ACOs are able to get professional medical advice day or night, in offices, by phone, and even via e-mail. Quick treatment helps maintain health and reduces cost.
Coordinated Medical Care Team - It is estimated that unnecessary care or “overtreatment” kills 30,000 Americans a year. Care teams and care coordination are very important when you need to see more than one doctor, or you need to be hospitalized. In the ACO model, coordinating your care among all your care providers ensures that each knows what the other is doing for you.
Electronic Health Records - The Institute of Medicine (IOM) has estimated that 44,000 to 99,000 patients die in hospitals each year due to medical errors and that there could be at least 1.5 million preventable adverse drug events in the U.S. every year. A high percentage of U.S. patients have reported that medical records and test results were not available during a visit or that tests were duplicated unnecessarily.
Shared electronic medical records help both your primary care doctor and specialists know your entire health history, the drugs you have been prescribed, and your test results. This improves the cost, quality and safety of the care you receive.
These five principles are shared by Accountable Care providers who take responsibility for the cost and quality of the care they provide to their patients. Patients receive better care at a lower cost and have a greater PEACE of mind.
NEW GOVERNMENT INITIATIVE: STRONG START FOR MOTHERS AND NEWBORNS
The Department of Health and Human Services initiative, Strong Start for Mothers and Newborns, aims to reduce preterm births and improve outcomes for newborns and pregnant women. CMS recently announced the two strategies of this initiative to achieve these goals:
A public-private partnership and awareness campaign to reduce the rate of early elective deliveries prior to 39 weeks for all populations.
A funding opportunity to test the effectiveness of specific enhanced prenatal care approaches to reduce the frequency of premature births among pregnant Medicaid or Children’s Health Insurance Program (CHIP) beneficiaries at high risk for preterm births.
The Strong Start effort to test new approaches to prenatal care is a four-year initiative to test and evaluate enhanced prenatal care interventions for women enrolled in Medicaid or CHIP who are at risk for having a preterm birth.
The goals are:
1.Determine if these approaches to care can reduce the rate of preterm births
2.Improve the health outcomes of pregnant women and newborns
3.Decrease the anticipated total cost of medical care during pregnancy, delivery, and over the first year of life for children born to mothers in Medicaid or CHIP.
Three approaches to enhanced prenatal care
This initiative will test three evidence-based maternity care service approaches that enhance the current care delivery and address the medical, behavioral, and psychosocial factors that may be present during pregnancy and contribute to preterm-related poor birth outcomes.
Awardees will test one of the three following interventions but cannot use funds to supplement or supplant any funding sources, including Medicaid and CHIP reimbursement:
Group prenatal care that incorporates peer-to-peer interaction in a facilitated setting for health assessment, education, and psycho-social support.
Comprehensive prenatal care facilitated by teams of health professionals, including peer counselors.
Services include collaborative practice, intensive case management, counseling, and psycho-social support.
Enhanced prenatal care including psychosocial support, education, and health promotion in addition to traditional prenatal care. Services provided will expand access to care, improve care coordination, and provide a broader array of health services.
Awardees receiving Strong Start funds can administer more than one approach to enhanced prenatal care at multiple provider sites; however, individual provider sites can administer only one of the three enhanced approaches.
Strong Start awardees will be serving women in the areas with the highest preterm birth rates in the country, including areas that are among the top ten prematurity and infant mortality counties according to the Centers for Disease Control and Prevention.
Eligibility criteria
To be eligible to participate in the Strong Start initiative, applicants had to be:
1. Providers of obstetric care (for example, provider groups or affiliated providers and facilities);
2. State Medicaid Agencies, in partnership with providers;
3. Medicaid managed care organizations (MCOs), in partnership with providers; or
4. Conveners in partnership with other applicants. The convener could be a direct applicant or could convene and support other organizations to become applicants.
Examples of conveners include professional trade associations or other health service related organizations.
Program requirements
Strong Start awardees will participate in monitoring and evaluation activities to ensure that quality care is being delivered.
Participants will be expected to provide the CMS Innovation Center performance metrics consistent with the goals of the initiative on a quarterly basis.
Awardees will report information on gestational age and birth weight for the infants of the mothers participating in one of the three approaches to enhanced prenatal care.
Participants will also provide the gestational age and birth weight data on births from a historical baseline period that spans at least two years prior to the start of the intervention.
Participants also submit quarterly progress reports on the specific uses of the cooperative agreement funds, assessment of the overall project implementation, and other specific information.
They must also submit quarterly data reporting on operations, utilization, and outcomes.
CMS will provide technical assistance, analytic support, and coordination to help participants launch their interventions to reduce premature births. As with all Innovation Center initiatives, participants will participate in opportunities for shared learning and dissemination with others.
About the Innovation Center
The CMS Innovation Center was created by the Affordable Care Act to test new innovative payment and service delivery models.
The Center is committed to testing models to help the Medicare, Medicaid, and CHIP programs deliver better care for beneficiaries while reducing costs.
Can Greater Value for Medicare Beneficiaries Come True?
The Centers for Medicare & Medicaid Services (CMS) has released proposed policies in an attempt to insure its beneficiaries will get greater protections, value, and care in the services they receive.
The 2014 Advance Notice and draft Call Letter takes important steps to improve payment accuracy for Medicare Advantage (Part C) and in Medicare prescription drug (Part D) plans for 2014, without shifting costs to beneficiaries.
Costs of the defined standard Part D plan will be lower in 2014:
The standard Part D deductible will be $310, down from $325 in 2013.
Cost-sharing amounts will also be lower.
Note: Since 2010, the Affordable Care Act has affected Medicare Advantage premiums by lowering them 10 percent. Enrollment in Medicare Advantage plans is expected to increase by an estimated 28 percent through this year.
A proposed rule, beginning in 2014, plans to implement the Affordable Care Act’s minimum medical loss ratio (MLR) requirements for Medicare Advantage and prescription drug (Part C and Part D) plans limiting how much plans can spend on marketing, overhead, and profit.
Plans must spend at least 85 percent of revenue on clinical services, prescription drugs, quality improvements, and/or direct benefits to beneficiaries in the form of reduced Medicare premiums.
Enrolled seniors and individuals with disabilities will get more value and better benefits as plans spend more on health care.
Note: Similar MLR requirements are already benefiting consumers in the private health insurance market.
Proposed guidance in the Advance Notice and draft Call Letter released February 15, 2013, increases value and protections for beneficiaries:
Lower Out-of-Pocket Drug Spending: The 2014 defined standard Part D prescription drug benefit will have lower co-payments, a lower deductible and increased coverage for Medicare beneficiaries in the Part D prescription drug coverage gap, or “donut hole”.
Note: Enrollees with liability in the “donut hole” will receive coverage and discounts of 52.5 percent on covered brand name drugs and 28 percent on covered generic drugs.
Greater Protection for Beneficiaries: CMS proposes to require Part D plan pharmacies to obtain enrollee consent prior to each delivery, unless the enrollee personally requests the refill. This proposal is in response to complaints from beneficiaries who have received and been charged for unnecessary and unwanted prescriptions because of “auto-ship” services.
CMS proposes for Medicare Advantage enrollees protection from significant increases in costs or cuts in benefits, and, for the 2014 contract year, proposes reducing the amount of any permissible increase to $30 per member per month (down from $36 per member per month in previous years).
In addition, the 2014 statutory updates to the annual parameters for the defined standard Part D prescription drug benefit are:
Part D Benefit Parameters
2013
2014
Defined Standard Benefit
Deductible
$325
$310
Initial Coverage Limit (Total drug costs after deductible before hitting coverage gap)
$2,970
$2,850
Out-of-Pocket Threshold (Total amount beneficiary pays before hitting catastrophic phase)
$4,750
$4,550
Minimum Cost-sharing for Generic/Preferred Multi-Source Drugs in the Catastrophic Phase
$2.65
$2.55
Minimum Cost-sharing for Other Drugs in the Catastrophic Phase
$6.60
$6.35
Retiree Drug Subsidy (RDS)
Cost Threshold (Amount RDS sponsor must spend before claiming the RDS subsidy)
$325
$310
Cost Limit (Amount after which RDS sponsor claims no RDS subsidy)
$6,600
$6,350
(Note: The changes from 2013 to 2014 are rounded to the closest appropriate level.)
Comments on the proposed Advance Notice and draft Call Letter are invited from the industry and other stakeholders and must be submitted by March 1, 2013. The final 2014 Rate Announcement and Call Letter including the final MA and FFS growth percentage and final benchmarks will be published on Monday, April 1, 2013.
For updated information about the Medical Loss Ratio provision for the private health insurance market under the Affordable Care Act, please view the report available at:
http://www.cciio.cms.gov/resources/other/index.html#mlr.
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