Kimberly S. Hodge, PhDc, MSN, RN, ACNS-BC, CCRN- K
Director, ACO Care Management & Clinical Nurse Specialist
Franciscan ACO, Inc. – Central Indiana Region Indianapolis, IN
OBJECTIVES
By the end of this session the participant will be able to:
Verbalize the potential impact of an aging population on the healthcare system.
Differentiate Medicare and commercial Accountable Care Organizations.
Articulate the rationale for why Advanced Practice Nurses are important to achieving ACO goals.
Brainstorm APN opportunities within an ACO structure.
AGING POPULATION
United States of America: We are getting older!
http://www.seniorsworldchronicle.com/2009_11_16_archive.html
AGING POPULATION
http://www.census.gov/population/socdemo/statbriefs/agebrief.html
AGING POPULATION
US Census
http://www.census.gov/compendia/statab/2012/tables/12s0034 .pdf
AGING IMPACT ON MEDICARE
Aging population = MORE BENEFICIARIES More beneficiaries = MORE MONEY NEEDED 2011: National Health Expenditure (NHE) accounted for 17.9% of Gross Domestic Product (GDP) or $2.7 TRILLION
2011: Medicare spending was 21% of NHE or
$554.3 BILLION in 2011
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html
AGING IMPACT ON MEDICARE
Medicare spending is estimated to have grown 6.3% in 2011 and PROJECTED TO GROW AN AVERAGE OF 6.1% PER YEAR over the projection period from 2011 – 2021…
Per person, personal health care spending for the 65 and older population was $14,797 in 2004, 5.6 times higher than spending per child ($2,650) and 3.3 times spending per working- age person ($4,511).
GIVEN HISTORICAL DATA AND PROJECTED GROWTH:
HOW DO WE KEEP MEDICARE SOLVENT?
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html
WHAT IS AN ACO?
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, WHO COME TOGETHER VOLUNTARILY TO GIVE COORDINATED HIGH QUALITY CAREto their patients.
The goal of coordinated care is to ensure that patients, especially the chronically ill, get THE RIGHT CARE AT THE RIGHT TIME, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/
WHAT IS AN ACO?
http://youtu.be/MZaa1QROQAU
ACOS
Types
Medicare Shared Savings Program
Advance Payment ACO Model
Pioneer ACO Model
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/
ACOS
Medicare Shared Savings Program
The Centers for Medicare & Medicaid Services (CMS) has established a Medicare Shared Savings Program (Shared Savings Program) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs.
Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/
ACOS
Advance Payment ACO Model
The Advance Payment Model is designed for physician-based and rural providers who have come together voluntarily to give coordinated high quality care to the Medicare patients they serve.
Through the Advance Payment ACO Model, selected participants will receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure.
http://innovation.cms.gov/initiatives/Advance-Payment-ACO-Model/
ACOS
Pioneer ACO Model
Designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings.
It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program.
It is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients.
http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/
ACOS
http://kff.org/report-section/a-primer-on-medicare-what-is-medicares-role-in-delivery-system-reform/
COMMERCIAL ACOS
Anthem Cigna Others…
MEDICARE ADVANTAGE PLANS
Anthem, Humana, United Healthcare, Advantage Health Solutions, etc…
http://www.hhs.gov/budget/fy2015-hhs-budget-in-brief/hhs-fy2015budget-in-brief-cms-medicare.html
ACOS…
Think about the integration of care across the continuum…
http://www.aurorahealth care.org/aboutus/continuum/art/continuumchart.gif
ACO QUALITY MEASURES
ACO Quality Measures: 4 Domains
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
Domain Measures Patient /
Caregiver Experience
Getting Timely Care, Appointments, and Information
How Well Your Providers Communicate
Patients’ Rating of Provider
Access to Specialists
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status
ACO QUALITY MEASURES
ACO Quality Measures: 4 Domains
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
Domain Measures Care
Coordination / Patient Safety
Risk Standardized All Condition Readmission
Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults
Ambulatory Sensitive Conditions Admissions: Heart Failure (HF)
Percent of Primary Care Physicians who Successfully Qualify for an Electronic Health Record (HER) Program Incentive Payment
Medication Reconciliation
ACO QUALITY MEASURES
ACO Quality Measures: 4 Domains
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
Domain Measures Preventive
Care
Influenza Immunization
Pneumococcal Vaccination for Patients 65 Years and Older
Body Mass Index (BMI) Screening and Follow-Up
Tobacco Use: Screening and Cessation Intervention
Screening for Clinical Depression and Follow-Up Plan
Colorectal Cancer Screening
Breast Cancer Screening
ACO QUALITY MEASURES
ACO Quality Measures: 4 Domains
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
Domain Measures At Risk
Population
Diabetes Mellitus: Hemoglobin A1c Control (8 percent)
Diabetes Mellitus: Low Density Lipoprotein Control
Diabetes Mellitus: High Blood Pressure Control
Diabetes Mellitus: Tobacco Non-Use
Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease
Diabetes Mellitus: Hemoglobin A1c Poor Control
ACO QUALITY MEASURES
ACO Quality Measures: 4 Domains
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
Domain Measures
At Risk
Population Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (100 mg/dL)
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Coronary Artery Disease (CAD): Lipid Control
Coronary Artery Disease (CAD): Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF 40%)
APNS AND ACOS
Potential roles
Care coordinator
Manager
Director
Vice President
Provider
APN OPPORTUNITIES IN
ACOS
kimberly.hodge@franciscanalliance.org kshodge@gmail.com
