Care Coordination

The Importance of Care Coordination Beyond Cost Containment, and the Use of Health Analytics to Reach the Magic Quadrant

Care coordination has been successful in many cases where applied in U.S. health care, but direct association with cost containment is not necessarily one of them. Care coordination is frequently associated to cost containment, especially when discussing advanced payment models and shared savings, but the two should be considered separately, and on their own merits: care coordination is in pursuit of enhanced patient care, while cost containment is best associated with reduced spending on care opportunities. Cost containment is essentially juxtaposed to care coordination as cost containment must imply reducing provisioning of services, while care coordination increases them.

The takeaway here is not that either care coordination or cost containment should be pursued, but that both are important in achieving better patient care and lowering operating costs for your practice. In many cases, especially for rural practices, the two are related and symbiotic. In theory, cost containment can be achieved by redirecting patient services to less costly services with equivalent outcomes: reducing emergency room (ER) visits is an excellent example where patients can receive better care from visiting their primary care physician (PCP) than from visiting the ER for many situations. Effecting such a change may be difficult or impossible without the use of care coordination. The PCP may simply be too busy providing “primary care” to instill the importance of the change to those high cost patients. Having care coordination in place is where the two concepts converge, entering that magic quadrant of better patient care and lower cost of care.

Care coordination is often associated with lower costs in the romantic conversation of doing more for our patients will lead to lower costs. Economically, such an equation is impossible. But care coordination is not strictly an economic equation, it is at its foundation, a response to populations that need a higher level of care to thrive. Responding to that need is in the highest and best interest of the patient. Unfortunately, the reality of most practices does boil down to an economic equation, and for these practices the word “triage” is a familiar term. Enter health analytics and informatics. Use of advanced analytic tools such as Lightbeam Health is one of the fastest ways to reach the magic quadrant. Care coordinators are put to their best use by addressing the patients that need care the most, and simultaneously reducing the cost of care by effectively rerouting the most expensive patients to high value care opportunities and away from wasteful spending.

Is your practice engaged in care coordination? Are your care coordinators making the best use of their time and your dollars by reaching the highest cost patients who need the most care? Engage with Caravan Health’s clinical practice leadership to find out what you can do to increase your practice’s effectiveness of care.

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Contact information:
James Foster
IS Supervisor
Caravan Health

McWilliams, J., Cost Containment and the Tale of Care Coordination, 2016, New England Journal of Medicine, 275, pp 2218-2220

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


Read Our February 2016 Care Coordination Newsletter

Quality of Life. We aim to arm Care Coordinators with a tool box of knowledge and resources so that they can provide the best care possible to their patients. Our February Care Coordination Newsletter delves into Chronic Obstructive Pulmonary Disease, covering various adjustments and treatments Care Coordinators can make to ensure patients living with COPD have an improved quality of life. We also share information about the COPD Foundation’s community website, which will provide Care Coordinators with an expanded network of information and support.

Click here to read our February 2016 Care Coordination newsletter.


Read Our November Care Coordination Newsletter

Escalating medication costs are of concern for consumers and providers of healthcare.  In our November Care Coordination Newsletter, read about the innovation of one Community Care Coordinator who is helping her patients maximize Medicare Part D benefits and other innovative medication assistance programs to achieve affordable options for successful medication management.

Click here  to read the November issue of Care Coordination newsletter.

National Quality Forum Calls for Mandatory Quality Reporting for Rural Providers

Participation in CMS quality measurement and quality improvement programs is mandatory for all rural providers”, according to a report released by the National Quality Forum’s Rural Health Committee. The NQF report, Performance Measurement for Rural Low-Volume Providers, outlines recommendations that transition rural providers into value based purchasing and is further evidence that rural performance measurement is here to stay. It is no longer a choice. Secretary Burwell’s laid the track when she announced that 30% of all Medicare provider payments will be tied to alternative payment models (e.g., accountable care organizations (ACOs), primary care medical home (PCMH) models, bundled payment arrangements, etc.) by the end of 2016 (50 percent by the end of 2018). HHS also seeks to tie 85 percent of Medicare fee-for-service payments to quality by 2016 (90 percent by 2018) through programs such as the Hospital Value-Based Purchasing and the Hospital Readmissions Reduction Program.

You can view the report here. 

The recommendations in the NQF report furthered our dialog of how we can accomplish Secretary Burwell’s goal given the challenges faced by the rural providers. Specifically, the report called for the need for rural-relevant measures that a can address low case volume explicitly and consideration of a sociodemographic risk adjustment It proposed the use a core set of measures, along with a menu of optional measures for rural providers and encouraged the measures that are used in patient-centered medical home models. It recommended performance be tied to incentive payments, not penalties. And most striking was the accelerated timeframe with the creation of incentive-only payment programs for rural providers within three years; and mandatory participation in CMS quality improvement programs within two to four years.

Rural providers have a legacy of policies and programs that often do not “fit” current local needs and often have misaligned incentives that undermine high-value and efficient care delivery. Cost-based reimbursement, for example, has not created incentives for value-based models that invest less in technology-intensive medical services and more in health promotion, care coordination, improved clinical care quality, enhanced patient safety and experience, and better population health at lower per capita costs. Nonetheless, rural communities have enormous potential for achieving the objectives of the Triple Aim. Smaller systems can be more nimble in making the kind of change necessary to succeed in the current environment.  New delivery arrangements may be pursued more easily among local clinical, behavior and public health providers who know and trust one another. Together, they share a collective interest in improving their community’s well-being. While the transition from the status quo will require a change in the balance and configuration of essential services, greater integration within and across service sectors, attention to population health, and shared governance and management structures, it is doable.   My take away – rural providers can no longer stay idle. The greatest threat to the sustainability of rural healthcare systems is not participating in rural performance measurement. The market will force doctors and patients to choose high value providers and partners – and rural will be left behind.

Summary of Key Rural Provisions in the 2016 Physician Fee Schedule

Following is a summary of the key rural provisions in the 2016 Physician Fee Schedule.

Advanced Care Planning:
CMS is approving new CPT codes 99497 (initial 30 minutes) and 99498  (subsequent 30 minutes) for explanation, discussion and completion of Advanced Directive forms for Medicare beneficiaries. The estimates of payment are $86 in an office setting and $80 in an inpatient setting. While this can now be part of the Annual Wellness Visit or a physician visit, and does qualify as an RHC visit, it cannot be billed in an RHC in addition to the All-Inclusive Rate.

Rural Health Clinics and HCPCS Codes:
RHCs will now be required to record all HCPCS codes for services provided during a visit, even though additional payment will not be forthcoming. It is essential that RHCs completely detail the services they provide. There is much debate about whether RHCs are not providing the same standard of care services as most fee-for-service clinics (such as smoking cessation counseling) or are they simply not documenting them because it does not affect payment. If you are doing the work, make sure you document it, or this could have negative consequences under payment reform. The new requirement for recording the HCPCS codes on the bill has been delayed from January 1st to April 1st 2016.

RHCs and FQHCs can Bill for Chronic Care Management (CCM) Codes:
Beginning in January 2016, RHCs and FQHCs can now bill $41.92 per patient per month under Part B for CCM services outside of the All-Inclusive Rate. Thanks, CMS! You heard our prayers.

New Quality Measure for the Medicare Shared Savings Program:
CMS is adding a new Statin Therapy for the Prevention and Treatment of Cardiovascular Disease in the Preventive Health domain.  The measure reports the percentage of beneficiaries whoe were prescribed or were already on statin medication dureing the measurement year and who fall into any of the following three categories: active diagnosis of clinical atherosclerotic cardiovascular disease, LDL-C > 190 mg/dl, or diabetics with LDL-C of 70-189 mg/dl. This new measure will be pay-for-reporting only for the next three years.

Changes in Assignment of Beneficiaries for the Medicare Shared Savings Program:
Primary care services that are delivered in a Skilled Nursing Facility (POS code 31) will no longer be considered for patient attribution.

To see all of the changes in the PFS, please go to

Secretary Burwell Throws Down the Gauntlet

On January 26th, Secretary Burwell laid out an ambitious goal of having “30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016.Our goal would then be to get to 50% by 2018.”

See her blog post on the topic here.

She continues, “Our second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018.” Hmmm. More than 20% of fee-for-service payments are for rural beneficiaries, yet RHCs, CAH’s and FQHC’s are the only providers whose payments are not tied to quality and value. No PQRS, no value-based purchasing, no value-based modifiers, not even Medicare Meaningful Use. How will the Secretary achieve her goal without offering incentives for rural providers? As one CEO wrote to me yesterday, the times they are a’changin.

Expect more to come from HHS. We’d like to help the Secretary achieve her goal with better incentives for rural providers to participate in ACOs. Better payments, better assignment, more flexibility and having Medicare pay residual cost-sharing for our seniors to encourage them to get care in their rural ACO would go a long way.

Please review our comments letter here.  If you agree, go to and send in a comment on CMS-1461-P supporting our ideas. Comments matter! And so do rural beneficiaries!

Announcing Our New ACOs: 30 Rural Health Systems Participating In Six ACOs In Nine States In 2015

This is a proud day for the National Rural ACO.  Today, we issued a news release about our new ACOs.  Read on and you’ll see why we are so excited.

The National Rural ACO announced today it has successfully formed five additional ACOs in 2015 for rural providers following in the steps of the first ACO started in 2014. Using the organization’s unique collaborative model, fifty-two entities, including 28 rural and critical access hospitals, 42 rural health clinics, 12 federally qualified health centers and 9 private physician practices in thirty rural health systems were able to afford and qualify for the Medicare Shared Savings Program. More than 65,000 attributed Medicare beneficiaries from the states of Texas, California, Washington, Iowa, Indiana, Missouri, Oregon, Illinois and Michigan are now benefitting from the program under the care of 1,300 clinicians.

Our newest ACOs are:

  • National Rural ACO
  • Reid ACO, Suburban Health ACO
  • American Rural ACO
  • Northwest Rural ACO
  • National Rural ACO II

In almost all cases, the rural hospital sponsored the program and invited local providers to join at no charge. Although annual revenue for the hospitals ranged from $5 million to $758 million per year, and they all included employed or contracted physicians, only one applicant had enough beneficiaries to form its own ACO. All of the others joined forces to achieve the minimum number of beneficiaries and to reduce the cost of participation in proportion to what rural providers can expect to earn from the program.

The National Rural ACO provides comprehensive services including claims data access and analysis, evidence-based medicine leadership, care coordination coaching and the governance, legal and compliance services needed to succeed.

“The National Rural ACO’s unique model of collaboration is the first of its kind to enable rural providers to receive higher reimbursement for improving the care they deliver,” said Tim Putnam, CEO of Margaret Mary Hospital and chair of the board for the first National Rural ACO. “We can access the same type of powerful data, waivers and programs that urban ACOs can for about the same cost as it would be to hire one person to figure out how to get into the program.”

Please contact us if you would like more information about our new ACOs.