WILEMS RESOURCE GROUP
HEALTH CARE Compliance & engagement Solutions
Medicare Accountable Care Organizations (ACOs) are responsible for the overall quality and cost of health care provided to their traditional Medicare beneficiary (Beneficiary) populations. That statement is not as simple as you might think for Medicare Shared Savings Program (Shared Savings Program) or Next Generation Model (NextGen) ACOs. The Centers for Medicare and Medicaid Services (CMS) aligns Beneficiaries to ACOs through a claims-based methodology requiring Participants to provide the plurality of primary care services received by a Beneficiary. For Shared Savings Program ACOs, this methodology is applied retrospectively at the end of the performance year. In other words, the ACO does not know which Beneficiaries they are responsible for each year until after the year ends. While NextGen ACOs were granted prospective alignment, the plurality of care standard can still cause significant heartburn of its own within both programs. Participants often find that loyal Beneficiaries are not aligned to the ACO. This can happen for any number of reasons; a common example is snow-birds who receive much of their care in another state each year. Moreover, while this claims-based alignment methodology does consider claims billed by mid-level providers and specialists, the Beneficiary must have at least one visit with a primary care provider, or one of the specialists used for alignment. As a result, practices that regularly use mid-level providers or include large numbers of specialists often have difficulty maintaining attribution for their patient populations.
Recently, CMS launched a new initiative called “Voluntary Alignment” for all Medicare programs, not just ACO, that encourages Beneficiaries to actively visit MyMedicare.gov and select the primary care physician they believe is most responsible for coordinating their care. This Voluntary Alignment process will supersede the claims based methodology, and will be applied prospectively in both the Shared Savings Program and NextGen Model. The benefits are obvious - stabilizing alignment rosters and allowing ACOs to focus care coordination resources on a pre-determined population. In all the excitement for this initiative, ACOs may overlook a few drawbacks or nuances that could directly impact their performance:
Even with these hurdles, ACOs will likely benefit from the ability to stabilize the roster. The question then becomes, how can ACOs take advantage of this new initiative? CMS will notify Beneficiaries about Voluntary Alignment via an updated “Medicare & You” handbook. ACOs should also actively communicate with Beneficiaries, participating providers and office staff about Voluntary Alignment. It’s an excellent opportunity to further engage Beneficiaries in their health and educate them on their provider’s participation in an ACO. As ACOs develop a communication strategy they should consider the following:
Voluntary Alignment is the next iteration of Beneficiary assignment for Medicare ACOs. Is your ACO ready to take advantage of the benefits of a more predictable population of aligned Beneficiaries?
 “Accountable Care Organizations (ACOS): General Information.” Centers for Medicare & Medicaid Services. Last updated: September 5, 2017. https://innovation.cms.gov/initiatives/ACO/
 “Medicare Shared Savings Program: Shared Savings Losses and Assignment Methodology Specifications.” Centers for Medicare & Medicaid Services. Last updated: April 2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/Shared-Savings-Losses-Assignment-Spec-V5.pdf
 “Voluntary Alignment: For Medicare Shared Savings Program ACOs.” [PowerPoint slides]. Centers for Medicare & Medicaid Services. August 23, 2017.
Wilems Resource Group is a boutique consulting firm specializing in Compliance and Engagement solutions for the Medicare Shared Savings Program and Next Generation ACO Model. We measure success on our ability to help our clients understand program requirements, determine the appropriate level of acceptable compliance risk, and create programming that meets all regulatory requirements. We build customized compliance and engagement programs for ACOs, physicians, practice managers, and beneficiaries. We are #raisingourlegacy.
Kimberly Busenbark & Maddie Short, Wilems Resource Group
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