In today’s environment, Providers are generally paid a fee for each service rendered. Therefore, Providers increase revenues by increasing patient visits and working longer hours to see more patients a day. However, the Centers for Medicare and Medicaid Services (“CMS”) policy and program initiatives have been driving to a new model, Accountable Care. Accountable Care takes the old model of fee for service and turns it upside down.
Under an Accountable Care program, Providers are paid based upon their quality outcomes. The Patient Protection and Affordable Care Act (“Healthcare Reform Act”) created the Shared Savings Program which is an Accountable Care Organizations (“ACO”). The ACO model is intended to require Providers to create a new legal organization that is financially and clinically integrated. This clinical and financial integration is intended to coordinate care among hospitals, physicians and suppliers as well as integrate reporting on financial and clinical metrics. The ACO would be paid for the services rendered, but instead of increasing revenues with increased visits, if the ACO can minimize the costs associated with delivering care to at least 5000 beneficiaries then the ACO benefits by sharing in the monetary savings. Thus, Providers will be motivated to reduce patient visits and instead focus upon the patients achieving quality outcomes. However, if the Providers fail to achieve quality outcomes, the Providers will not be eligible to share in the savings. Specifically, the proposed ACO require Providers to report on sixty-five (65) measures that focus upon the following policy priorities: (1) patient/caregiver experience; (2) care coordination; (3) patient safety; (4) preventative health; and (5) at risk patient populations. The Providers will be scored on each measure within each policy priority. If the quality benchmark is achieved, the ACO Provider is eligible to share in the monetary savings.
This initiative of scoring a Provider’s care will likely change the culture and behavior of Provider practices. Because the Provider will be scored based upon the patients’ perceived experiences, Providers must focus upon the factors that impact patient satisfaction scores, i.e. wait time, friendly staff, ease of scheduling. Providers must also consider what information technology systems will be used to coordinate care with other providers and what clinical decision support tools can be used to prevent medical errors and promote patient safety. Likewise, engaging the patients to modify their behavior will be a critical component of improving quality outcome scores and protecting the Provider’s ability to receive payment. This concept of reporting on quality measures and tying payment to the quality outcomes will change not only a Provider’s business plan for profitability/sustainability, but may change the actual practice patterns of Providers.
In addition to the ACO concept, CMS has established other programs that require quality reporting to obtain reimbursement. For example, physicians can receive an increase in their reimbursement from CMS if they participate in the E-prescribing program. Likewise, physicians that report on quality benchmarks in the Physician Quality Reporting Initiative (“PQRI”) are also eligible for financial incentives. Further, the Centers for Medicare and Medicaid Innovation (“CMI”) demonstration projects also focus upon improving quality outcomes and reducing costs. Therefore, the focus on quality clinical outcomes will likely continue to drive change in behavior while facilitating payment reform.