National Rural ACO

News, commentary and opinion on the ongoing transformation of our health care systems.

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National Rural ACO Featured In HCPLAN Newsletter

I am excited to share this Q&A about the National Rural ACO and our work with ACOs that was recently featured in the HCPLAN Newsletter.

HCPLAN Newsletter | August 12 | Participant Spotlight: National Rural ACO (see pg. 4)

The National Rural ACO pools knowledge, patients, and resources so that independent community health systems can participate in new population health-based reimbursement models. Lynn Barr, MPH, Chief Transformation Officer, spoke with a member of the CAMH team on July 28.

[CAMH]: What is the National Rural ACO’s goal, and what key approaches are you using?

Barr: We focus only on rural communities. Though 20% of Medicare beneficiaries get care in rural America, these health systems are far behind in population health management. Many have not done care coordination, performance measurement, etc. Our goal is to help them make improvements in quality and cost. For example, their aggregate quality scores in 2014 were 60%. We want to get to 70-75% in year two and 80-90% in year three. We also aim to reduce costs by 10% within the first three-year cycle. For 2016, we’re putting in applications to CMS for 26 rural ACOs with 179 health systems in 32 states. Our biggest goal is getting people started on the journey of population health management. We are very excited about that.

Our first step is to set up care coordination in each community. Every member hires a care coordinator. This is great for the patients, and it helps lower costs and improve quality. Second, we add annual wellness visits. A provider can hit 11 quality scores in an annual visit. About 5O% of our members haven’t been doing annual wellness visits. It’s a billing issue. In other fee-for-service clinics, when a patient comes in for a regular visit, the provider can also do the wellness visit and bill for both. Rural providers and Federally Qualified Health Centers aren’t allowed to bill separately. That’s a huge disincentive. The third component is reducing Emergency Department (ED) utilization. Rural beneficiaries use the ED for primary care because rural providers aren’t available 24/7. Fifty percent of rural ED visits are for primary care. Total ED utilization per beneficiary is 20% higher than the national average. We want to bring that down significantly. Another component is analytics. We provide data to support the other three components. It makes a big difference. For example, we found that the cost of home health in one of our ACOs is $1000 per month, while the national average is just $300. There is a great opportunity to make a difference.

[CAMH]: Who can join? Is there a typical profile of a member?

Barr: All our members are “community health systems.” Typically there is one hospital with a group of affiliated physicians. Our goal is to take that delivery network and integrate it with others to improve performance and coordinate care.

[CAMH:] How much variety is there across your ACOs and why?

Barr: Rural providers are very diverse. Our hospitals range from 4 to 250 beds. Our communities have anywhere from 175 to 8,000 attributed patients, with the average being about 1,000 attributed lives.

[CAMH:] To what extent are rural health systems’ challenges unique?

Barr: One of the biggest differences is size. Almost all of these health systems don’t have the minimum 5000 attributed beneficiaries, which is why we need to combine them. They have extremely limited capital; lack of funding is a huge barrier. They also have very little IT infrastructure, so we have to provide it for them. Almost all have electronic health records. Rural providers are right up with the rest of the country for EHR adoption, but their EHRs are very simple. We use the Lightbeam Health population management system to pull all their claims data together with their clinical data. Data is critical. We get It to them quickly and show them how to use it. Their care coordination program is built around claims data.

[CAMH]: Are the components of your ACO approach different from what might work in urban ACOs?

Barr: Yes, they are very different from urban ACOs. The top rural health system concerns are building relationships with patients and building secondary and tertiary networks. They have few or no networks and highly fragmented care. For example, the 175 patients in our smallest community with were seen in 75 different Part A facilities in the last 2 years. Our focus is around engaging the community and, as a result, improving cost and quality. Urban ACO communities are huge. You can’t really understand the concept of community until you live and work in a rural hospital. Everyone shows up for a hospital board meeting and cares about their providers. In small communities, patients have deep relationships with their providers. We can succeed and thrive by serving their needs.

Urban ACOs don’t focus on community per se, because the ACO is just one of many players in town. Their patients change providers more often, so they focus on services they deliver and how to maximize cost and quality improvements. Our biggest advantage is that the patient population tends to be more stable. They may go other places for care, butthey tend to come back home. For example, if we do a good job on colorectal screening, we can wipe outcolorectal cancer in our town. That is very satisfying. Also, our approach wouldn’t work so well in urban settings where there is competition. There isn’t competition among our rural health systems, so it is easier to build collaboration. On the other hand, we are similar to urb an ACOs, insofar as this is a lot of hard work for everyone.

Barr: Our first ACO started in the 2014 performance year. By end of the first year, it had reduced utilization in every category except physician visits. It is too early to tell for the others. We only have 90 days of data so far, but there are some promising trends.

[CAMH] What in your mind are the most important lessons you’ve learned so far about standing up and running ACOs in rural health systems?

Barr: We changed the program quite a bit after the first year. We initially thought start up would be simpler. It takes a lot more interaction than we had assumed. We had to increase staffing to work more closely with each partner. It is more labor intensive, but rewarding. We really appreciate the support we are getting from the CMS Center for Medicare and Medicaid Innovation. We feel that they are committed to helping rural providersand to our success.

Click here to read the full newsletter,

September 4, 2015 Accountable Care Organization, CMS Read more >

CMMI Alters Rules for the ACO Investment Model — More Rural Health Systems Will Qualify

On June 25th, the Center for Medicare and Medicaid Innovation (CMMI) announced two important changes to the rules for rural providers who are applying for the Medicare Shared Savings Program this year to become ACOs. Click here to read about the two important changes.

They have removed the 10,000 life cap for rural ACOs. This is very important because it is very difficult to estimate how many lives will be attributed to rural ACOs. By removing the cap, many more rural ACOs will qualify.

They are now also providing AIM funding to ACOs that applied in 2015.

Thanks for listening CMMI and CMS! Your support for rural providers is obvious and well-appreciated. Together we will create healthier communities and lower healthcare spending. Now the work begins.

June 29, 2015 Accountable Care Organization Read more >

The National Rural ACO: Hundreds of Rural Health Systems, 50 ACOs, and the New World of Value-Based Payments

When we began this journey, our central premise was that every rural community should not have to figure out how to accomplish population healthcare on their own and that the population numbers had to reach enough scale to be affordable. We planned to develop the systems with our pilot group, test our scale up with second year enrollments and be ready to serve the market the third year. Our plan was to have 10 communities in year one, 30 communities in year two and 100 communities in year three. For every 10 communities we brought on board, we would need a project manager and a care coordination coach. We partnered with high-performing rural networks to engage the Executive Directors who lead the ACOs, and provided our own as well. We tested the scale up for 30 communities this year. Our plan worked and we are now ready to scale to the next level to support the 2016 applicants.

We have hired most of our senior staff and are currently refining our programs with the 2015 ACOs. Every member has their data, has hired Care Coordinators and has met with us monthly to work on redesigning the workflows at the clinic to optimize quality and reduce cost. We are constantly learning and sharing best practices across the country. The scale up of ACO Managers and Care Coordination coaches has been successful and can be replicated to meet the demands of our 2016 cohort.

The biggest change to our model in 2016 will be the addition of management and financial consultants to the team. These consultants will work hand in hand with the member’s CFO to ensure a smooth transition to value-based payments. Our 2016 members will get to choose from premier firms such as Alliant, BKD, Blue and Company, Coker, Eide Bailly, HFS Consultants and Quorum to attend steering committee meetings, review member financials monthly and make recommendations to improve performance. Alternatively, members can choose to work with our local network partners such as Hometown Health, Indiana Rural Health Association, Monida Health Network, New Mexico Rural Hospital Network, Northland Health Alliance, Southeast Texas Hospital System, Washington Critical Access Hospital Network, Washington Rural Health Collaborative, and the West Virginia Critical Access Hospital Network.  These partnerships allow us to access local expertise while training our partners in these new programs.

Finally, we have selected four regional Vice Presidents who will serve as the Executive Directors of their ACOs and who will work with our member’s consultants to develop relationships with other payers in their state to implement similar gain-sharing arrangements for their Medicaid and commercial patients.

By leveraging our experience, scale and depth, we are the best opportunity for success in the transformation of your delivery system and preparation for the new world of value-based payments.

 

 

June 23, 2015 Accountable Care Organization, Medicare Shared Savings Plan, Payment Reform, Read more >

Legislative Alert: Senators Thune and Cantwell Introduce Legislation to Allow Patient Assignment to Rural Providers for Medicare Shared Savings Program

CALL YOUR CONGRESSMAN TODAY TO SUPPORT THIS IMPORTANT LEGISLATION

Today, rural providers struggle to have the majority of their patients attributed to them for the Medicare Shared Savings Program because the Affordable Care Act requires patients to be assigned based on the plurality of care by a physician.

As a result, rural providers who rely heavily on Nurse Practitioners to deliver care only get about one-third of their patients attributed to them, compared to almost two-thirds of patients attributed to urban providers. This makes it twice as hard for rural providers to qualify for the program and means we get paid half as much for the same work.

Senators Cantwell and Thune have introduced legislation to fix this wording issue in the Affordable Care Act. Please take a moment now to have a member of your staff reach out to your Senator and tell him or her that it is very important to support this bill. It is budget neutral and fair to everyone, including our rural patients.

The Senators’ press release follows below. We really appreciate their support, and especially their comment, ““The rural ACO model has the potential to greatly improve access to high quality care in rural parts of our state.” Yes it does.

Screen Shot 2015-06-15 at 3.35.25 PMSENATORS INTRODUCE BILL TO IMPROVE MEDICAL PAYMENT MODELS FOR RURAL HEALTH CARE ORGANIZATIONS

WASHINGTON, D.C. – Last Friday, U.S. Senators Maria Cantwell (D-WA), Patty Murray (D-WA) and John Thune (R-SD) introduced bipartisan legislation that would improve Medicare Accountable Care Organizations (ACO’s) for patients and health care providers.

The Rural ACO Improvement Act of 2015 promotes access to coordinated, patient-focused health care services in rural and underserved areas by implementing improvements to the way patients are assigned to the Medicare Shared Savings Program, a key Medicare ACO.  The legislation allows Medicare to include primary care visits by nurse practitioners, physicians’ assistants and clinical nurse specialists, as well as primary care services furnished in Federally Qualified Health Centers and Rural Health Clinics, in assigning patients to an ACO.  The changes aim to make ACO assignment more accurate and inclusive in communities lacking primary care physicians, while enabling health care providers to attain enough ACO participants to make the model successful.

“Washington state has long been an innovator in the delivery of efficient and coordinated health care.” said Cantwell.  “This legislation advances that innovation by promoting health care that puts the health of patients at the forefront, particularly in rural communities that lack primary care physicians.  Improvements to Medicare’s delivery of health services mean higher-quality care for Washington state beneficiaries and lower costs for taxpayers.”
“I’m focused on building a health care system that works for Washington state families, and to do that, we need to make sure that families are able to get high quality care right in their own communities,” said Senator Murray. “Our legislation will help more families in Elma, Shelton, and communities throughout our state benefit from innovative delivery system reforms that are designed to put patients and families first and save taxpayer dollars, by helping to bend the cost curve and improve quality of care.”

“While health care reimbursement models are transforming, it’s important to level the playing field so rural health care organizations can participate in new payment models, like ACOs, that reward well-coordinated, high-quality, low-cost care,”said Thune. “This bipartisan legislation takes several common-sense steps that would not only help rural ACOs get off the ground, but would also result in more coordinated access to value-based rural health care for Medicare beneficiaries across the country.”

“We commend the Senators’ legislation which will ensure those patients who have chosen to receive primary care services from a nurse practitioner are eligible to be included in an ACO,” said Dave Hebert, CEO of the American Association of Nurse Practitioners.  “This change will result in increased access to the quality primary care that nurse practitioners provide especially for those patients in rural and underserved communities.”

“The rural ACO model has the potential to greatly improve access to high quality care in rural parts of our state. But to achieve that goal, it must reflect the realities of who provides care in these communities,” said Scott Bond, CEO of the Washington State Hospital Association. “This bill recognizes the critical role nurse practitioners and physician assistants play in providing access for residents of rural communities.”

Accountable Care Organizations, or ACO’s, are groups of hospitals, doctors, and other health care providers who voluntarily join together to coordinate care for a specific patient population.  In ACO’s, health care providers are responsible for effectively managing the health and wellness of patients: when an ACO delivers high-quality care at a lower cost than traditional fee-for-service spending, the ACO recoups part of the savings.  Created by Congress in 2010, the Medicare Shared Savings Program is a voluntary program enabling health care providers to share savings with Medicare if they beat cost targets and achieve specified quality measures.

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June 5, 2015 Accountable Care Organization, Healthcare Policy, Medicare Shared Savings Plan, Payment Reform Read more >

Top Twelve Reasons Independent Providers Should Join Their Community’s ACO

Payment is changing. Becoming a member of the National Rural ACO will help you prepare for the new payment models that will take effect in 2019. These new payment models will be determined using quality scores and the relative costs of your patients. National Rural ACO will work with your office staff to achieve success under these new models in the following ways:

  • Reaching quality scores in the 80th to 90th percentile (rural baseline is ~60%).
  • Promoting annual wellness visits.
  • Completely and accurately coding all current chronic diseases at each visit.
  • Pooling data to understand why your patients are more expensive than regional and national averages (e.g., certain diseases, post-acute care, drugs, DME, etc.) and deploying strategies to constrain those costs.
  • Coordinating care for your chronically ill patients.
  • Qualifying for Patient-Centered Medical Home Certification.
  • Providing 24-hour access to medical advice for your Medicare patients.
  • Getting complete claims data from all sources on your Medicare patients so that you can better understand the full spectrum of health care services they use, yet frequently do not report to their physician.
  • Getting drug refill information on your patients.
  • Obtaining important waivers of Start, Anti-Kickback Statute, Patient Inducement and Anti-Trust.
  • Gaining access to similar shared savings programs with other payers.
  • Preparing to be as ready as possible for future value-based payments.

Please contact us with your questions.

 

May 19, 2015 Accountable Care Organization Read more >

Rural Hospitals Face May 1 Deadline for ACO Signup

Time is running out for rural hospitals and healthcare systems to sign up to join the National Rural ACO and to qualify for special, one-time only, federal grant funds that can cover the full cost of membership for new applicants in 2016. The Center for Medicare and Medicaid Services (CMS) has committed $114 million dollars in grant funds to help rural health providers make the transition to an accountable care organization in 2016.

Now is the time to act.  Apply today to become an ACO.

Hundreds of rural health systems have expressed interest in joining the National Rural ACO this year. This is a unique opportunity to join a proven and successful rural ACO model that will position community health systems for the future; teaching them how to get paid more under the new value-based reimbursement models, while improving care for their community.

Watch this video to gain insight and important information about becoming an ACO and the path to a sustainable future for rural healthcare organizations.

The deadline for consideration is May 1, 2015. The fastest, easiest way to complete the required application letter on time is to go to the www.nationalruralaco.com website and click on the Apply Now button.  The application is non-binding, but for those who miss the approaching May 1st deadline there may be no other opportunity to qualify for the one-time grant funds from CMS.

Many rural providers believe they cannot participate in Accountable Care Organization programs because of cost, the limited numbers of beneficiaries or because they will be forced to take downside risk. National Rural ACO has developed a program that allows rural RHCs, FQHCs and hospitals to join regardless of size and with no downside risk. The program is a bonus program only and does not affect fee-for-service payments or cost-based reimbursement in any way.

At the National Rural ACO, we are working with rural healthcare providers across the country who are ready to join the movement to Accountable Care Organizations (ACOs) that improve the sustainability of healthcare systems through better health outcomes, better patient experience and lower costs, which result in higher payments.  Join us today. 

April 16, 2015 Accountable Care Organization, Healthcare Grants and Funding Read more >

Call Your Congressman TODAY About the SGR Fix — What About Rural Health Clinics and FQHCs?

The “Doc Fix” is in play once more and looking to move toward approval. The attached document outlines how Congress intends to alter physician fee schedule payments, making 25% of physician payments variable based on cost and quality by 2020.

One of the key components of this legislation provides special incentives for clinicians who participate in Advanced Payment Models. “Professionals who receive a significant share of their revenues through an APM(s) that involves risk of financial losses and a quality measurement component will receive a five percent bonus each year from 2019-2024. A patient-centered medical home APM will be exempted from the downside financial risk requirement if proven to work in the Medicare population.”

Guess what? Providers that practice in RHCs and FQHCs (who are not paid under the Physician Fee Schedule) are not eligible for those five percent bonuses. This is a SUBSTANTIAL INCENTIVE that will leave rural providers behind in their costly efforts to transform their practices.

Call your congressman today and ask that the SGR Fix includes language that requires CMS to provide similar incentives for Rural Health Clinic and FQHC providers to join Advanced Payment Models.

March 23, 2015 Accountable Care Organization, Healthcare Grants and Funding, Payment Reform, Read more >

CMS Wants to Hear From You!

CMS has released a Request for Information on transforming clinical practices. It is important for you to review this document and submit your comments to CMS no later than March 16, 2015. You can find the form to fill out here.

We must engage with CMS on these new payment models to define a unique approach for rural health systems. The National Rural ACO, a 501(c)3 organization governed by our founding members, supports a population health model where the rural health system is accountable for the care for its community. It preserves cost-based reimbursement, but allows us to earn more by coordinating care for our patients. The key elements of this model are that the community who lives in the primary service area of the hospital is assigned to the health system, who will proactively support them whether they get care locally or out of town. Critical to this model is the provision of Medicare claims data to the rural health system so we can identify patients who need our help, and also be able to evaluate the cost and quality of our referral network.

What are your ideas for payment reform? Let CMS know! And let us know, too. Rural providers need to lead the discussion. Submit your comments today!

March 4, 2015 Accountable Care Organization, CMS, Healthcare Policy, , Read more >

CMS Wants to Hear From You!

CMS has released a Request for Information on transforming clinical practices. It is important for you to review this document and submit your comments to CMS no later than March 16, 2015. You can find the form to fill out here.

We must engage with CMS on these new payment models to define a unique approach for rural health systems. The National Rural ACO, a 501(c)3 organization governed by our founding members, supports a population health model where the rural health system is accountable for the care for its community. It preserves cost-based reimbursement, but allows us to earn more by coordinating care for our patients. The key elements of this model are that the community who lives in the primary service area of the hospital is assigned to the health system, who will proactively support them whether they get care locally or out of town. Critical to this model is the provision of Medicare claims data to the rural health system so we can identify patients who need our help, and also be able to evaluate the cost and quality of our referral network.

What are your ideas for payment reform? Let CMS know! And let us know, too. Rural providers need to lead the discussion. Submit your comments today!

March 4, 2015 Accountable Care Organization, CMS, Healthcare Policy, , Read more >

CMS Pledges More Than $300 Million to Support Rural Health Transformation

The first Rural ACO Summit in Washington DC last week was a huge success. We engaged in terrific discussions with policy makers, made new friends among rural providers looking to enter the program, and connected rural ACO pioneers across the country. The presentations are available to download here.

Now, there is much work to be done and very little time to get the grant funding available to rural providers. Applications are due to CMS no later than July, and it takes at least two months to complete the application process.

HHS Secretary Burwell’s historic announcement telegraphs the future:

“Our first goal is for 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. 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.”

Most rural providers are exempt from these special payments, so it’s business as usual, right?

Wrong.

If you could see what ACOs see because they have the data….

Rural providers will typically have the highest UNIT costs and will have lower quality scores because they do not participate in PQRS or other quality programs and don’t know where to focus their efforts. You can’t improve what you can’t measure.

The reality is that our cost per beneficiary is lower, but nobody can see that data except for rural ACOs. Rural providers can’t tell this story without the data to prove it. Under the proposed new payment models, within a few years, a typical urban cardiologist could risk losing $100,000 – $300,000 per year in income if his patients are high-cost or if their quality scores are low, and much of this is out of his direct control – it depends a lot on where patients get primary care. It will be in his financial interest to only work with high-quality, low-cost providers, but most rural providers will appear to be low-quality and high-cost due to our lack of participation in ambulatory quality reporting and the way cost data will be presented to them.

Rural providers need to find ways to excel in ambulatory quality and to tell our story of lower costs per beneficiary. We need to help our patients prevent illness and/or navigate their disease. This is the essence of population health management, an essential skill and service of the 21st-century healthcare system. Becoming an ACO will get you where you need to go.

CMS wants rural providers to get into the population health game this year. To do so, they are funding up to 75 rural ACOs who apply in 2015 with $114 million. They are also providing $228 million in technical assistance, under the Practice Transformation Network, to those not yet ready to become an ACO. You must sign up this year to get subsidized assistance. Practice Transformation Networks will be announced this summer. ACO applications must be submitted by July, 2015. National Rural ACO can help.

Get started today, or sign up for our webinar on February 25th at 2:00 PM EST.

February 12, 2015 Accountable Care Organization, CMS, Healthcare Grants and Funding, Healthcare Policy Read more >