Population Healthcare and the impact on ACO Benchmarks

Accountable Care Organizations have become quite popular alternative to Medicare Advantage Plans, yet a tiny percentage of the Medicare Shared Savings Program (MSSP) ACOs are earning the lion’s share of the bonuses. This phenomenon is unlikely to change until the ACO embraces Population Healthcare principles in the management of their patient’s care.
To level set, Population Healthcare is the holistic management of individual’s wellness status predominantly by the primary care physician (PCP). In addition, Population Healthcare is not an event, rather an ongoing activity performed predominantly by PCPs working in conjunction with their patients at the point of care. Finally, revenue for each ACO Member is heavily weighted by the Hierarchical Category of Condi tons (HCC’s) identified and managed by the PCP.
MSSP ACO attribution based model assigns membership based on the physician most seen by the senior citizen in the previous calendar year. Assignment does not consider the specialty of the provider. In theory, this should be the PCP, yet a surprisingly large percentage of senior citizens never see a PCP in a given year. It is virtually impossible for population healthcare to exist without a PCP managing the care.
ACO success is tied to the healthcare savings relative to the ACO benchmark. ACO benchmarks are not just a given number from CMS, rather a reflection of the illness severity of the membership attributed to the ACO. In effect, the more engaged the PCP is in the practice of Population Healthcare, the better quality of life the attributed senior citizen will have and the greater the probability of the ACO generating a bonus.
MSSP ACO Benchmark’s are set for a three-year period in the contract with CMS. CMS uses a three year look back on the attributed members diagnosed healthcare conditions as a material piece to the calculation of the benchmark. Through the proper engagement of PCPs practicing Population Healthcare, the benchmark at contract renewal can be set at the appropriate level for the illness severity of the attributed membership. If the benchmark does not reflect the illness severity of the attributed patients, it is very unlikely that the MSSP ACO will ever achieve a bonus.
The ability to impact at the point of care and helping the PCP’s diagnose and chart their patient’s chronic conditions is the key to success for ACOs participating in the MSSP model. it is imperative for the ACOs to embrace Population Healthcare and engage the PCPs in a meaningful way. The challenge will be creating the tools and incentives to encourage the PCPs to be more thorough in the documenting and coding of their patient’s conditions.

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