Accountable Care Organization

Caravan Health Accountable Care Symposium to Feature Training on Access and Continuity Solutions

Join hundreds of accountable care pioneers to learn how rural hospitals, clinics, small practices and independent providers can achieve better outcomes and higher earnings.

Austin, Texas – November 15, 2016 – Caravan Health will be providing hands-on training for ACO’s, CPC+ participants and forward thinking primary care practices that want to learn simple techniques that improve care, lower cost and help practices earn significant bonuses under MACRA. The two-day symposium will be held January 11 and 12, 2017 at The Pointe Hilton Tapatio Cliffs in Phoenix, Arizona.

In addition to other population health-focused curriculum, the Symposium will train practices on how to implement the following access and continuity programs:

  • Provide a 24/7 nurse-advice line to triage patients and reduce the call burden on the practice; directing patients to the practice only when appropriate.
  • Teach your staff to empanel patients based on proven methodology, measure access and continuity, and rebalance patient loads as appropriate.
  • Help your staff use claims data to develop diabetic, cardiology and pulmonology panels, identify high value specialists for collaboration and organize quarterly meetings with you, your specialists and the care team to review your panels.
  • Help you implement Alternative Visits, including teaching you and your staff about scheduling, documentation and tracking methodologies.

“Leaders who attend will leave the Symposium with an understanding of exactly what needs to be done in 2017 in order to succeed in their ACO, CPC+ and MACRA+ programs,” stated Lynn Barr, CEO of Caravan Health.

The first day of the symposium will be dedicated to policy: explaining the interaction between MACRA and advanced payment models and showcasing real world experiences from pioneers of accountable care and practice transformation. The second day will feature hands-on workshops that will provide instruction on how to simply and affordably implement chronic care management and behavioral health interventions, in addition to wellness, risk adjustment and stratification programs. A special workshop will be dedicated to MACRA’s new Advancing Care Information category, providing practical tips on how to implement the workflows that will achieve the highest scores.

Participants that are currently enrolled in the Caravan Health ACO or CPC+ programs or are participating in a Practice Transformation Network may attend the Symposium at no cost if they register by December 15, 2016. A complete agenda and registration are available through the Caravan Health website

About Caravan Health:
Caravan Health helps providers implement population health programs with affordable, end-to-end solutions that achieve outstanding results.


Bryan Hagar
Communications Director
Caravan Health
916 542 4583

Final Rule MSSP Program

By LeeAnn Hastings, Director of Policy and Compliance

The Physician Fee Schedule (PFS) final rule was released by CMS in early November. The rule broadly establishes payment rates for physicians and makes other changes to the Medicare Part B program for calendar year 2017 (CY2017). Among the changes finalized for 2017 include important modifications to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) and their participant providers.

In the final rule, CMS created some important flexibility for providers that participate in an ACO and looking ahead, an opportunity for providers to increase the certainty of their patient population.

Typically, an ACO is responsible for reporting required quality data on behalf of its providers. Providers that do not report this data are currently penalized, or in the case of ACO participants, if the ACO does not report on their behalf. With the new rule, CMS will now allow providers to independently report their quality data, which in the event their ACO fails in its obligation, will prevent the provider from facing a penalty. The rule allows physicians to back-report for both the 2015 and 2016 performance years; and will carry forward the policy as we shift to payment under the Quality Payment Program (QPP) in the 2017 performance year.

CMS also finalized its proposal to explore a voluntary attestation process for 2018. Under this system, patients would be able to declare their “home” doctor, and the ACO would know in advance that such patients were assigned to the ACO. More details on this process will be released through sub-regulatory guidance and outreach.

Finally, CMS used the final rule to make adjustments to the quality measure set for 2017. More information on technical changes to quality measures and quality validation is contained in the PFS Shared Savings Program brief HERE.

In future blog posts we will discuss important coding changes in the final rule as well as the expanded Diabetes Prevention Program.

Monica Bourgeau to Speak on Value-Based Payment Model Success During 2016 Pre-Learning & Action Network Meeting

Portland, Oregon – October 6, 2016 – Monica Bourgeau, Executive Director of the National Rural Accountable Care Consortium, will present the business case for the Practice Transformation Network (PTN) at the 2016 Pre-Learning & Action Network (LAN) Fall Summit Meeting on October 24, 2016 in Washington, DC.

The LAN Summit brings health care professionals from across the nation to facilitate discussion on developing and implementing Alternative Payment Models (APMs). During the pre-meeting, Ms. Bourgeau will share her expertise on helping hundreds of practices and rural providers successfully adopt value-based payment models as a PTN participant through the National Rural Accountable Care Consortium

“Alternative payment models are shifting the way the nation pays for health care,” says Ms. Bourgeau. “This movement is establishing a sustainable delivery system that values quality over volume which better meets the needs of patients and providers.”

In 2015, the National Rural Accountable Care Consortium was awarded a Transformation of Clinical Practice Initiative grant to transition providers into new payment models. Under the Consortium’s program, small and rural primary care practices are able to begin the transformation to the new value-based payment models at no cost.

The PTN program infrastructure has helped practices reduce per-capita spending while improving care and patient satisfaction. More than 90% of the Consortium’s ACO Investment Model (AIM) applications were successful, making up more than 50% of all AIM ACOs in the nation.

To learn more information about the National Rural Accountable Care Consortium, please visit


Bryan Hagar
Communications Director
Caravan Health
916 542 4583

Payment Model a Success for Providers, Patients and Medicare

The Advanced Payment Model demonstration project is complete. The Model was designed to test whether pre-paying shared savings would result in higher participation in the model from independent physicians and rural providers. It also tests whether such participation will lower costs and/or improve the quality of care for Medicare Beneficiaries. The ACO Investment Model (AIM) follows the same principles as Advanced Payment but also allows providers employed by Critical Access Hospitals to participate in the program.


The average Advanced Payment ACO generated $2 million per performance year, almost twice as much savings per year as the average MSSP ACO. Advanced Payment model ACO’s also saved almost five times as much per beneficiary at $241.40 per year, vs. $58.64 per beneficiary per year for all MSSP ACO’s. The program saved the trust fund $21.5 million over three years.


For the 31 ACO’s that remained in the Advanced Payment program for three years, the average quality score increased from 90.2% to 92.9% by the third year.


Thirty-six of the one hundred new MSSP ACO’s in 2016 are ACO Investment Model (AIM) ACO’s, an updated version of the Advanced Payment model, and more than two-thirds of them are solely rural. Most AIM participants say they would not participate in the MSSP without AIM support. The 2016 AIM program increased rural participation in ACO’s five-fold.


ACO participation appears to have more impact in small and rural practices with limited experience in managing care when compared to all MSSP ACO’s. Small and rural ACO participants are likely to avoid penalties under MACRA’s quality payment program. Providing support for these practices at no net cost to the government is in the public interest.

In conclusion, the Advanced Payment model is successful in helping small practices and rural providers participate in the MSSP while improving quality and lowering per capita cost, and provides a net savings to the Medicare Trust fund. The Secretary should exercise her authority under the ACA to make the program permanently available to small and rural practices.

ALL MSSP ALL Advanced Pay
Per ACO Per Year $1,009,871 $1,975,039
Per Beneficiary Year $58.64 $241.40
Average Savings 0.58% 2.28%
Total Beneficiary Years 16,275,327 850,880
Total Savings $954,328,267 $205,404,040
Estimated Total Advanced Pay $80,684,908
Estimated Advanced Pay Repayment $38,369,312
Shared Savings Payments $1,298,712,390 $141,596,556
Net Savings (Loss) -$344,384,123 $21,491,888


CY2017 Physician Fee Schedule Proposed Rule Continues Trend Towards Value-Based Payments

CMS’s 2017 Physician Fee Schedule (PFS) proposed rule offers a lot for organizations interested in transformation to celebrate. In addition to making a number of tweaks to the Shared Savings Program that demonstrate CMS leadership are listening to provider feedback, the proposed rule removes barriers for rural health care organizations to offer more preventative and consultative services.

Most importantly, CMS proposes to remove the requirement for direct supervision in rural health clinics and federally qualified health centers when providing comprehensive care management (CCM) services. When CMS first finalized CCM as a billable service, the agency determined that for rural clinics and federally qualified health centers the primary practitioner must directly supervise all aspects of the care. In the proposed rule CMS  would allow such facilities to use general supervision for services incident to CCM, just as currently allowed in a standard physician office.

CMS also simplified the conditions for practitioners operating in all settings to provide CCM services, removing cumbersome requirements for a comprehensive pre-visit as well as written agreement to receive services and share health information. They also propose important new payments for care coordination and behavioral health integration. Caravan Health will assist you in implementing these new codes once approved.

Additionally, in a significant sign that CMS is thinking about our rural members, two new telehealth codes are proposed that will allow clinicians to offer advance care planning remotely.

CMS also proposes a new program focused squarely on prevention in high risk populations. The Medicare Diabetes Prevention Program would begin January 1, 2018 and offer an opportunity for providers to partner with local community organizations or even host prevention programs themselves. CMS is seeking comments on all aspects of the new program, and we expect to see at least one more round of additional rule-making on this before the program rolls out.

Finally, CMS is proposing a few new quality measures and sun-setting others. They also propose changes to the audit process and are considering beneficiary self-assignment.

Click here to read Caravan Health’s full analysis of the proposed rule.

We will have a webinar to review the proposed rule on Tuesday, Aug. 23 at 9am PT/11am CT/12pm ET. To join, log in to, participant code 5004777. If you are unable to access the web-audio function, dial 303.248.0285.

Comments on the proposed rule will be accepted by CMS until 5pm EST September 6, 2016. A final rule is expected no later than November 1, 2016.


LeeAnn Hastings
Director of Policy & Compliance
Caravan Health

CPC+ Practice Application Open in 14 Regions

This information is provided by the Centers for Medicare and Medicaid Services

On August 1, CMS opened the application for practices to apply for Comprehensive Primary Care Plus (CPC+), the largest-ever initiative to improve primary care in America. CPC+ rewards value and quality through an innovative payment structure to support comprehensive primary care.

In CPC+, CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations, and Medicare Advantage plans in 14 regions across the nation.

Click this link to view a pdf map showing the 14 CPC+ regions and provisionally selected payers:

Want to learn more about CPC+?

  • Get your questions answered in the Practice FAQs.
  • Register for one of the 20 upcoming CPC+ Practice Open Door Forums in August and September.
  • Watch the CPC+ Video Series to get an overview of CPC+ payment innovations and care delivery transformation.
  • Submit a CPC+ application via the online portal today through 11:59pm ET on Thursday, September 15.
  • Download the CPC+ toolkit: CPC+ In Brief, CPC+ Care Delivery Transformation Brief, and CPC+ Payment Innovations Brief and Case Studies.

At CMS, we believe CPC+ is the future of primary care in America. We are pleased to partner with aligned public and private payers across the country to support up to 5,000 practices delivering the care that best meets the needs of their patients and improves health outcomes.


The CPC+ Team

Caravan Health / National Rural Accountable Care Consortium Sign Up More Than 10% of all Million Hearts Grantees

Austin, Texas – July 26, 2016 – Caravan Health and National Rural Accountable Care Consortium announced today that they were successful in signing up more than 10% of all Million Hearts practices, including the majority of rural practices accepted into the program.  Million Hearts is a national initiative with an ambitious goal to prevent 1 million heart attacks and strokes by 2017. According to Lynn Barr, CEO of Caravan Health, “This is another major milestone for our providers. Million Hearts is a terrific program that will reduce the number of heart attacks in at-risk patients, while paying providers well to implement the program.”

At first Caravan Health was not able to recruit providers for the program because patients that were in Million Hearts were not eligible for Chronic Care Management fees, a net loss of $400 per patient per year. After notifying the Center for Medicare and Medicaid Innovation (CMMI) of the dilemma, CMMI modified the rule to avoid exclusion of Care Management Payment, but only three days before the application deadline.

Caravan Health’s customer service team dropped what they were doing and called and emailed hundreds of practices right up to the deadline, providing them with a sample application and encouraging them to apply. “Our providers will receive an extra $16 million for participation, and thousands of heart attacks will be avoided. Everybody wins.” says Tristan Del Canto, who manages the customer service team.

The Consortium and Caravan Health have a highly successful track record in helping providers apply for value-based payments. “More than 90% of our AIM ACO applications were successful and make up more than 50% of all AIM ACO’s in the nation,” says Monica Bourgeau, Executive Director of the Consortium. “In addition, the Consortium was awarded a $31 million Transformation of Clinical Practice Initiative grant to assist providers to move into value-based payments, and we have already enabled hundreds of independent, rural and safety net primary care practices join value-based payment models.”

The number of practices that have signed up for the National Rural Accountable Care Consortium’s Practice Transformation Network is more than four times what was anticipated in the grant application. Almost half of those practices are small practices in urban settings who benefit from setting up the same simple, sustainable programs of care coordination and wellness and prevention. Practices preparing for MACRA and other advanced payment models are provided software, training and 24/7 advice nurse hotlines at no cost under the Consortium’s program. The Consortium is a 501c3 organization which contracts its transformation services to Caravan Health.


Bryan Hagar
Communications Director
Caravan Health
916 542 4583

Qualify for Comprehensive Primary Care Plus Program by September 15 Deadline

Comprehensive Primary Care Plus (CPC+) will pay well-deserving primary care providers an additional $100,000 to $250,000 per year, in addition to fee-for-service, for care that has previously been largely uncompensated.

Today, primary care physicians spend many hours outside the exam room, documenting patients’ history and following up on referrals, but do not get paid for activities that are not face to face. CPC+ allows doctors to spend more time during the day with patients and less time after hours on paperwork.

Track 1 and Track 2 participants are paid $180,000 to $320,000 per 1,000 patients per year for Care Management Fees, respectively, and are also eligible for $30,000 to $48,000 per year in incentive bonuses. In both tracks of the program, practices must have a care coordinator, promote wellness, use claims data, have 24/7 access, align patients with providers and report on quality.

In addition to the aforementioned $320,000, Track 2 primary care providers can get as much as 71.5% of the reimbursement previously confined to face-to-face visits, using patient-pleasing methods such as phone, email, or text advice. All procedures and routine office visits are still fully billable under the physician fee schedule, sometimes for higher rates. In either track, beginning in 2019, the practice will also receive a MACRA payment of 5% of Part B billing for five years and will be exempt from the Quality Payment Program (if the practice has fewer than 50 physicians). Participation regions and states will be selected by August 1st.

Applications are due September 15. This is a multi-payer program.

The 5,000 practices that can participate in the model may be determining the fate of primary care payments for decades to come. The Comprehensive Primary Care Initiative was the most generous program to date under CMMI, and well received by providers, but only broke even in cost savings. It’s sequel, Comprehensive Primary Care Plus promises to go even farther in both the incentives and the requirements of the program. If successful, the Secretary has the power to make the program permanent, and CPC+ pioneers can define a bright future for primary care payments.

To be eligible, practices must already have a care coordinator, promote wellness, have 24/7 access, align patients with providers and use data for care. Most small practices will not qualify without focused effort to implement the qualifying programs in a short period of time. To get assistance, please go to