Some Facts About "Pioneer" Accountable Care Organizations

You know its pretty bad when a lead review article in the health reform-friendly journal, Health Affairs, likens the Shared Savings Program's Accountable Care Organization (ACO) model to an Edsel, "widely considered one of the worst cars of all time." 

All well and good, but what author Harris Meyer also did was update the Disease Management Care Blog on a parallel ACO program launched by the CMMS Innovation Center on May 17.

It's been dubbed "Pioneer."

Knowing that DMCB readers may be interested in some background about this "Pioneer" thingy, here's a quick summary of what the DMCB thinks are the more important parts:

Purpose:

This three to five year Pioneer ACO Program is tailored to fast-track health provider organizations that already have care coordination programs up and running to what the Feds believe is the next level: ACO status.  During the first 2 years, the candidate organizations will operate under a shared savings arrangement.  If successful, payments will transition, as the DMCB understands it, to a "population-based payment model" that involves a mix of capitation and fee-for-service reimbursements.

Money:

Payment to the participating ACOs will be based on historically projected and risk and inflation-adjusted per capita  targets. At the end of the various measurement periods, the Pioneer ACOs' claims expenses will be judged against their targets.  To get any money, they will have to be above a 1% threshold.   Once that is achieved, the shared savings will range from 60 to 75% and be capped at 10% of total expenditures.  Downside losses will also be possible. Like the Shared Savings Program, any unmet quality measures (to be defined in the final Shared Savings regulations) will also be used to subtract from the shared payment. CMS promises to provide historically, monthly and quarterly data reports.

Other insurers also have to join in and the number of their patients has to comprise more than 50% of the total. 

Last but not least, much of the payment details are being left intentionally vague so that CMS can be flexible.

Patients:

At least 15,000 Medicare beneficiaries (or, if rural, 5000)  have to be available in order for an organization to participate in Pioneer.  While the default is to assign patients prospectively, the organizations can ask for retrospective assignment.  Patients will not be locked into any network.

In the application process, these ACOs will also need to document how they are prepared to meet the needs and preferences of their patients with "patient centered care."  Patients will notified that they can call an 1-800 number with any concerns.  CMMI promises to analyze utilization data and audit any ACOs with claims patterns that suggest care is being withheld. 

What else?

The Innovations Center hopes 30 programs will eventually participate. If you are interested, it may be too late. Letters of intent were due June 30. The application process closes on August 19. 

A fact sheet is here.