STATE — Medicare recipients will soon have the opportunity to join an initiative that aims to reduce costs and provide better health care.
Across the state, Maine's health care providers are reorienting care delivery by creating Accountable Care Organizations (ACOs).
The 2010 Affordable Care Act authorizes the creation of ACOs and 89 groups across the country have agreements with the Center for Medicare and Medicaid Services (CMS) to provide care through the Medicare shared services initiative.
According to a press release from CMS, 2.4 million Medicare recipients are currently receiving care through the shared services initiative – CMS estimates the program will save the federal government $940 million over four years.
In the past, Medicare's traditional fee-for-service system gave providers incentive to deliver more frequent and expensive care, says Andrea Patstone, vice president for strategic initiatives at MaineHealth, a southern Maine provider network.
MaineHealth's ACO includes Stephens Memorial Hospital and Western MaineHealth in Norway. Independent physicians across the state are also included in the ACO.
"One of the roots of the crisis that we have in financing health care over the long haul is the reimbursement model ... is based on volume. The more services we deliver and sometimes the more expensive services we deliver, the more we get paid," Patstone says.
Under the new ACO model, providers are offered incentives to prove that they are reducing costs while providing quality care.
"They provide an opportunity for health care providers to get paid for taking care of patients the way we've always wanted to," Patstone explains.
An ACO has the opportunity to be reimbursed with 50 percent of the savings it generates, as long as it meets the rigorous standards outlined by CMS.
Standards include care coordination, patient safety, improved care for at-risk populations and appropriate use of preventative health services.
The reimbursement is reduced for every poor score an ACO receives on its standards. This provides a strong incentive for providers to reduce costs and deliver better care.
"If we don't deliver the right care, that's going to show up in our quality measures and we won't make any financial gain," says Patstone.
"It's an interesting way of aligning incentives for health care providers in a much more rational way than they've been aligned under some of the older models for payment," she continues.
Organizing an ACO means the provider receives fewer revenues, providing a huge incentive to provide better and less costly care – reclaiming a portion of the savings is the only way to mitigate that revenue loss.
In order to realize cost-saving, ACOs will rely on new systems to deliver appropriate and effective care to patients.
Providers in the ACO will coordinate care through sharing information and increasing cooperation – the goal is to provide better informed, more personal care, explains Bill Wypyski, CEO of Maine Community Accountable Care Organization, which contains nine Federally Qualified Healthcare Centers across the state, including one in Bethel.
By keeping track of patient's health data, the ACO can ultimately provide better preventative care, Wypyski explains – providers can compare service delivery and formulate best practices, he says.
"We're trying to understand people's use patterns so we can start to develop systems that will help them stay well, prevent illness [and] take care of chronic illness in a way that is better informed," he says.
Care coordinators will work with patients to make sure their health needs are being met. This allows the ACO to maintain a patient's well-being while reducing expensive visits to the hospital and emergency department unless they are necessary.
The approach is all about creating a system of care that values being proactive rather than reactive, he says.
There is no requirement to join the ACO, says Wypyski. Patients who would prefer not to join can continue to see their regular physician and operate on the traditional fee-for-service Medicare system.
Patstone says that Medicare recipients in the state stand to gain a lot from ACOs. Over 1,000 MaineHealth physicians provide care to around 30,000 Medicare patients and MACAO provides care to around 7,000.
Two other health care networks, Central Maine ACO in Lewiston and Eastern Maine Healthcare Systems ACO in Bangor, spread the web of service across the state.
"I think if we looked at Maine in comparison to other states in the country the coverage of ACOs across our health care market is probably one of the most, if not the most significant," says Patstone.
Even though the ACO model is currently only available for Medicare patients, Patstone says MaineHealth is actively in discussion with private insurance providers about opportunities to increase the availability of ACOs.