Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

CMS Reveals Medicare-Medicaid Accountable Care Organization

State-specific Medicare-Medicaid accountable care organization models will allow providers to take on accountability for Medicaid costs and quality of care, CMS stated.

By Jacqueline LaPointe

- CMS recently unveiled a Medicare-Medicaid accountable care organization (ACO) model that will allow participating providers in the Medicare Shared Savings Program to take on accountability for Medicaid costs and quality of care for dual-eligible beneficiaries.

New Medicare-Medicaid accountable care organization model will make providers financially accountable for dual-eligible patients

The Medicare-Medicaid ACO model will build on the current Medicare Shared Savings Program. In conjunction with states, CMS plans to develop state-specific Medicaid financial accountability methods and shared savings and losses arrangements.

Each state model will also have its own additional quality measures and ACO eligibility requirements.

“This model aims to provide improved care coordination for those enrolled in both Medicare and Medicaid, allowing providers to focus more on providing care for their patients rather than administrative work,” stated Patrick Conway, MD, CMS Acting Principal Deputy Administrator. “CMS continues to partner with and leverage the best ideas from states to transform our healthcare system to improve quality and care coordination. In the long run, this partnership will result in healthier people and smarter spending.”

The Medicare Shared Savings Program included 433 ACOs that covered approximately 7.7 million assigned Medicare beneficiaries as of April 2016. However, the Medicare ACOs did not have financial accountability for Medicaid spending and quality of care, even for dual-eligible beneficiaries assigned to their organization.

To reduce healthcare costs related to dual-eligible beneficiaries, CMS designed the newest ACO model to add Medicaid accountability to existing Medicare Shared Savings Program ACOs. Participants in the dual-eligible-specific model will take on financial and quality of care responsibility for beneficiaries in Medicare Part A, Medicare B, and Medicaid.

Without Medicaid accountability, CMS reported in August that Medicare Shared Savings Program ACOs generated over $429 million in savings in 2015, with 119 ACOs receiving shared savings payments.

The Medicare ACOs also improved care quality. The average quality performance increased by over 15 percent between 2014 and 2015 in four measures, including risk of future falls screening, depression screening and follow-up, blood pressure screening and follow-up, and pneumonia vaccinations.

By adding Medicaid accountability, CMS intends to bring the same cost reductions and quality improvements to the dual-eligible population.

CMS also designed the Medicare-Medicaid ACO model to promote alternative payment model participation among safety-net providers who tend to care for more dual-eligible beneficiaries. Under the model, safety-net ACOs will qualify to receive prospective Medicare shared savings payments to foster care coordination investments.

The federal agency will develop the Medicare-Medicaid ACOs with interested states. Through the model, states can earn shared savings payments if their Medicare-Medicaid ACOs produce Medicare savings for their dual-eligible enrollees. The ACOs will also share in the payments.

States that have a sufficient number of dual-eligible beneficiaries in Medicare and Medicaid fee-for-service can apply to participate. However, CMS will only select up to six states with preference given to states with low Medicare ACO saturation.

Selected states will work with CMS to create state-specific ACO model elements, such as Medicaid costs methodology, payment arrangements, and quality measures. States will also be able to include additional Medicare-Medicaid enrollees not assigned to the Shared Savings Program and/or Medicaid-only beneficiaries in the model.

To participate in the first 12-month performance period in 2018, states must submit a letter of intent to CMS by Jan. 20, 2017.

For future participation, states can submit a letter of intent for 2019 participation by Aug. 4, 2017 and for 2020 participation by Aug. 3, 2018.

Dig Deeper:

Understanding the Value-Based Reimbursement Model Landscape

What Are the Benefits of Accountable Care Organizations?


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