Making ACOs More Accessible for Long-Term and Post-Acute Care Providers

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) and the National Association of ACOs (NAACOS) have released recommendations on how to increase accountable care organization (ACO) participation among long-term and post-acute care (LTPAC) providers.

LTPAC providers face barriers to participating in ACOs due to misaligned program policies, such as those that determine which patients ACOs are accountable and those that set financial benchmarks and quality measures.

Fewer than 2,000 skilled nursing facilities (SNFs) participate in ACOs, representing less than 10 percent of SNFs nationwide. SNF participation is concentrated in a small number of ACOs, with less than 10 percent of ACOs accounting for nearly 75 percent of SNF participation.

AHCA/NCAL and NAACOS brought together different stakeholders, including long-term care representatives, ACO leaders, providers, patient advocacy organizations, and payers, to discuss how CMS can improve value-based arrangements to facilitate LTPAC provider participation.

The roundtable recommended that CMS prioritize alignment and participation options for beneficiaries residing in long-term care facilities. The agency should remove the long-term care nursing facility population from the Medicare Shared Savings Program (MSSP) and other shared savings models to prevent overlap and misalignment to community-based providers who no longer provide primary care to these beneficiaries.

CMS should also allow attribution at the facility level instead of the clinician level, add which ACO a patient is attributed to the common working file, and use retrospective alignment for institutional nursing home beneficiaries.

The financial methodology should be adjusted in ACOs so the reference population includes a similar rate of institutionalized patients, the stakeholders said. CMS should also use the concurrent risk adjustment model that is being tested in ACO REACH for the SNF population.

Recommendations on quality measurement included prioritizing metrics that encourage hospitals and healthcare providers to establish superior care transitions and discharge planning. In addition, CMS should improve data sharing on quality measures with value-based care entities to support partnerships between these entities and CMS.

The value-based arrangement landscape would benefit from data improvements, the stakeholders determined. For example, the Medicare system used to check benefits should list the ACO a patient is aligned to for prospective attribution participants, and CMS should regularly share performance data and utilization and cost data throughout the performance period.

CMS should leverage data-sharing networks to share real-time information, such as automated admission, discharge, and transfer feeds, with acute care and SNF providers. Providing additional funding and technical assistance and working toward full integration between SNF and physician records could also help improve ACO participation for LTPAC providers.

When discussing future model concepts, roundtable participants agreed on certain policies that CMS should adopt for developing a voluntary episode-based payment model for SNF providers that could be nested within an ACO. These models should address unresolved healthcare delivery system problems, improve patient outcomes while reducing healthcare costs, ensure scalability, and entail meaningful risk and reward for ACO participants.

In addition, the models should align with the Center for Medicare and Medicaid Innovation’s strategic vision, create a sense of predictability and stability, prioritize data-sharing, and be a voluntary model with adequate non-financial incentives.