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With Next Generation ACO model, accountable care meets value-based care


To anyone unacquainted with the inner workings of healthcare, the term "accountable care" may seem loaded.

Most industries readily embrace accountability. Look around your home or office and you see a plethora of products and services that come with money-back guarantees, 24-hour help lines and detailed instruction manuals.

Yes, this in no small part serves as a way for businesses to cover their hindquarters--hence the fine print on those guarantees and manuals--but it also demonstrates an acknowledgement that those same businesses accept some form of responsibility if what they offer fails to live up to your expectations.

That's rarely the case in healthcare. The industry, by and large, rewards inefficiency, waste, duplication and complication. But that's starting to change.

When the Department of Health and Human Services announced its intention to expedite the shift to value-based care for treating Medicare patients, FierceHealthPayer subsequently reported that the modest success of provider- and physician-led ACOs might stand in the way of the HHS value-based care plan. The main issues: Not enough risk and not enough benchmarks.

Enter the Next Generation ACO. Last week, the Centers for Medicare & Medicaid Services (CMS) announced the new Accountable Care Organization (ACO) model. It differs from the Pioneer ACO model and the Medicare Shared Savings Program in that it comes with more risk, more predictable financial targets and more rewards.

So far, healthcare experts laud the Next Generation ACO model, telling FierceHealthcare that the move away from shared savings and limited risk should push the industry toward capitated, value-based care.

As I opined a month ago, value-based healthcare can't come soon enough, so the CMS announcement represents an obvious step in the right direction. Linking "accountability" to "value"--two fundamental elements of commerce since, well, the beginning of commerce--should align healthcare with the industries making those products and services scattered around your home and office.

Last year, the Catalyst for Payment Reform found that value-based care now comprises 40 percent of provider reimbursements, with 15 percent of insurers' members linked to a provider participating in a value-based contract.

At the moment, the bulk of these agreements focus on specific episodes of care or types of patients. It makes sense: Although every patient is different, many patients have similar conditions that can be successfully addressed in a similar manner at a similar cost with similar results. This represents progress, but it targets the proverbial low-hanging fruit. Getting the remaining 60 percent of reimbursements, and the remaining 85 percent of members, will take time and effort.

It needs to happen. The industry needs to reach the morsels way up in the branches: The patients with multiple comorbidities, the frequent fliers and the folks with debilitating but treatable (if not outright preventable) conditions.

It's difficult, and it's risky, which is why the industry is usually content to leave those fruits for the treetop-dwelling creatures. It's also why CMS rightfully emphasizes risk in the Next Generation ACO.

I'm willing to bet that insurers will lead the way. Hardly a day goes by without a press announcement crossing the wire about Payer Z partnering with Provider Y to cover X number of members. Every statement mentions a desire to improve care quality and efficiency while cutting costs. (I picture some sort of elaborate electroshock system jolting the author of any press announcement for a healthcare audience that fails to mention the Triple Aim.)

Sure, those are just statements, and most focus on the vittles within easy reach. But providers often need a little prodding to shift even slowly from the fee-for-service model. (When it's a matter of definitely getting paid vs. possibly getting paid, it's hard to argue with that reticence.)

But a shift to accountable care means more than just different payment models. It also means taking a long, hard look at the work the industry does, how it pays for it, how it affects patients and how it accepts responsibility when the work it does fails to live up to expectations.

In other words, it also means making the phrase "accountable care" less loaded. - Brian (@Brian_Eastwood and @HealthPayer

Related Articles:
Next Generation ACO model lauded by healthcare experts
Next Generation ACOs: How they differ from Pioneer, MSSP models
CMS announces Next Generation accountable care organization model
Value-based healthcare can't come soon enough
There's one major problem with the HHS plan to speed up value-based performance
Feds speed plans for value-based payments
40 percent of provider reimbursements are for value-based care

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