Long-Term Care ACOs Present an Opportunity for the Most Complex Populations

Long-term care residents are historically overlooked and require high-cost, complex healthcare services. Accountable care organizations (ACOs) present an opportunity for providers to earn shared savings while improving care quality for this population.

Focusing on boosting ACO participation in the long-term care sector could help CMS achieve its goal of having 100 percent of fee-for-service lives covered by value-based programs by 2030. LTC ACO, the first value-based entity to serve Medicare beneficiaries in long-term care settings, has helped expand access to coordinated care for these residents.

“The bulk of this population is still participating in Medicare fee-for-service, so there’s a huge opportunity to get their providers participating in value-based care programs. Our mission is to reach as many lives as we can in the space,” Kristen Krzyzewski, senior vice president and chief of strategy and program development for LTC ACO, told RevCycleIntelligence.

“We’ve demonstrated that it is a good opportunity, both from a mission perspective and what we’re trying to accomplish for beneficiaries and the Medicare program, but then also from a business perspective, we’ve been able to put savings on the street and deliver on that promise to our participating providers.”

LTC first applied to be an ACO in 2015 for a 2016 start. The ACO is now in its second agreement period, which runs until 2024, and operates in the enhanced track—the highest track within the Medicare Shared Savings Program (MSSP).

During performance year 2021, LTC ACO had around 8,000 assigned lives, 96 percent of whom qualified as long-term institutionalized residents. The ACO had the second-highest benchmark in the country at $30,000 per year and earned the highest savings of any ACO participating in MSSP at $2,500 per beneficiary.

The value-based, coordinated care that ACOs provide members is especially beneficial for high-cost, high-needs populations like long-term care residents who are still covered by Medicare fee-for-service.

“These populations are the populations and patients that are using the services the most. They have the most chronic conditions, they have the [greatest] number of providers that they’re seeing, from primary care to specialists, and if left in fee-for-service, it tends to be an uncoordinated environment where the quality and cost outcomes are not optimal, to say the least,” Krzyzewski explained.

“There are all these incentives or disincentives and other interests that pull resources and attention away from this population and we’re trying to bring the attention and focus back to this population because the need is there, the complexity of care is there, [and] the chronic conditions are there that all would benefit from more aggressive preventive care, management, and oversight.”

The central relationship in LTC ACO is between the ACO and the primary care physicians. While the ACO’s ideal goal is to contract with the facilities as well, the COVID-19 pandemic and its accompanying challenges have made it difficult, Krzyzewski noted.

However, engaging with primary care physicians has enabled the ACO to succeed even as the sector grapples with staffing shortages.

“We’re driving the incentive and behavior changes at the primary care level. Because we see that motivation and willingness to engage with new tools and try to invest in care coordination through their own staffing and resources, we feel like that is what’s driving the change to potentially offset some of the other staffing challenges and things that have gone on as a result of Covid,” Krzyzewski shared.

In terms of increasing participation in long-term care ACOs, aligning incentives with providers who previously did not have incentives focusing on this population is a critical step.

The prospect of shared savings and incentive payments are also key drivers of participation. For performance year 2023, ACOs participating in an advanced alternative payment model (APM) will receive a 3.5 percent incentive payment.

In addition to financial benefits, ACOs can provide physicians with critical performance data.

“The opportunity to see the data on their population that they otherwise wouldn’t have access to is really of great interest to many of the groups who just are hungry for that data and want to improve upon their outcomes,” Krzyzewski mentioned.

While CMS policies surrounding ACOs and value-based care programs haven’t always kept the long-term care population in mind, Krzyzewski is optimistic about the recent provisions included in the 2023 Physician Fee Schedule (PFS).

“[CMS] made it clear in many places in the proposed rule and the final rule that it is their goal to attract providers serving higher-cost, complex populations—they didn’t come out and say long-term care, but higher costs in whatever shape or form,” she said.

For example, the advanced shared savings policy for renewing MSSP ACOs offsets negative regional adjustments for ACOs serving complex and underserved populations.

However, there is still room for improvement. Better risk adjustment that considers the unique characteristics of the long-term care population would lead to better outcomes and, thus, attract more participants.

“There’s an intention, a stated policy goal, and we’re just trying to help educate [CMS] on how they could do better to get the outcomes that they want to have more providers serving these populations participate in the program,” Krzyzewski concluded. “There’s a lot of upsides, but we’re a small voice and we’re trying to get more attention on these issues from a CMS perspective and leadership perspective so that we can help them accomplish their goals.”