When the largest independent physician group in the state of New York decided to move into the Next Generation Accountable Care Organization (ACO) model, it recognized post-acute as an area it needed to work on — and decided to include skilled nursing facilities in its plans.
CareMount Medical, which is based in Mount Kisco, N.Y., began its work in ACOs with a move into the Medicare Shared Savings Program (MSSP) model, when that program first began in 2012. At the time, it wasn’t taking on any downside risk, but as the government pushed organizations to do so, and offered some incentives, CareMount started looking at the Next Generation model as an opportunity, deputy chief medical officer Richard Morel told Skilled Nursing News.
And SNFs should be true partners in that endeavor, he and other executives at CareMount said.
“They need to be willing to put a little bit of skin in the game,” said Matthew Kamen, CareMount’s director of strategic analytics and development. “The more that our providers were willing to put skin in the game and engage with a little bit of downside risk, it signaled their ability and their willingness to invest in performing certain protocols and investing operationally so that we had aligned incentives.”
Tackling Post-Acute Spend
ACOs offer a single pool of funds for participating providers in the care continuum, and if the operators within it can maintain care quality while cutting overall costs, they receive a portion of the savings.
The Next Generation ACO model allows provider groups to take on higher levels of financial risk and reward than they could under the MSSP model, and that ACO structure resulted in $63 million in net savings for the government in 2016, according to an analysis from the Kaiser Family Foundation.
CMS put forward similar numbers in August 2018. At that time, the agency issued its Pathways proposal, which cut the time that ACOs can remain without downside risk to two years. That proposal was finalized in December of last year.
But when CareMount started looking at the Next Generation model as an opportunity for taking on downside risk and succeeding, it found some troubling trends in its post-acute spending, Morel said.
“As we looked at our spend and compared ourselves to multiple other ACOs across the country, we saw that the post-acute space was an area where we were somewhat of an outlier,” he told SNN. “We were in the top 20% for average spend for post-acute stay, top 20% for length of stay, which is directly tied to cost. But we also weren’t getting our money’s worth; readmission rates were high.”
CareMount, which is a 600-provider organization with 500 physicians and 100 advanced practice providers, became a Next Generation ACO on January 1, 2018. It knew from claims data where patients were going, and looked at Centers for Medicare & Medicaid Services (CMS) reports on quality, Morel said. But ultimately when it looked for SNFs to join its post-acute network, it decided to be as open as possible.
“We really opened it to all providers in our area who were willing to have the discussion with us,” Morel said. “Our thought was initially to cast a wide net and see who was willing to work with us. And then over time, our intent is to narrow that network.”
That opening took the form of a SNF summit in April 2018 with the larger SNFs in CareMount’s area to explain what the group was doing with the post-acute network, a request for quantitative and qualitative information on each of the facilities in its network to ensure adequate coverage, and examining discharge patterns from top hospitals to make sure there were viable options in each CareMount catchment area, Kamen said.
“Then we went through a process of collating all this data and negotiating with the SNFs that were willing to take risk and invest in this post-acute care transition process,” Kamen told SNN. “The actual network is formal; in the Next Generation ACO model, you’re allowed to develop a preferred provider network, which enables data sharing and also additional benefit enhancements for both the patient and the SNF.”
The expertise in each of the 23 SNFs in the network varies, and some are nonprofit, others for-profit. Some are operated by large organizations, while others are standalone. All of them have three or more stars in the CMS Five Star Quality Rating System, simply because it was required for them to be fully eligible for all the waivers in the program, Kamen said.
The contracts for the preferred provider network went live on January 1, 2019, and CareMount contracted with the SNFs using the Next Generation preferred provider agreement. By participating in such an ACO, preferred providers can have use a mechanism called the population-based payment, where providers can have a discount taken off the fee-for-service reimbursement that accrues to the ACO.
“Our ACO will then adjudicate rebates, or incentive payments, based on their performance on metrics that we contracted around,” Kamen said. “And that’s how we share risk with our partners. And then we use different utilization metrics and process metrics to identify how they’re doing in terms of collaborating.”
Being Good ACO ‘Citizens’
In terms of clinical expectations, CareMount has “citizenship metrics” laid out in the contracts and agreements with the SNFs, but it’s looking for collaboration, Alicia Beardsley, senior director of population health initiatives at CareMount, explained.
This means that the SNF has to identify ACO patients in real time when they’ve arrived and dedicate staffing to touch base once a week with CareMount staff and go through the roster of ACO patients in the SNF. Those conversations might cover projected discharge dates and any issues that might come up over the course of care that are unusual or that might impact discharge.
“The expectation is that they attend those sessions, that they provide us those real-time notifications, they give us a projected discharge date and update it accordingly during the stay,” Beardsley said. “And then when [the patient] is ready to go home, we offer [the SNFs] the benefit of scheduling those discharge appointments for them, those post-discharge appointments with either the primary care physician or the specialist. We also ask they provide us that discharge summary in a timely manner. And we do track that and provide a report card of what we call ‘citizenship,’ on how well they’re performing for that collaboration effort.”
Previously, CareMount’s physicians rarely, if ever, received the discharge summaries, and even if they did receive them, it was well after the window of a post-discharge visit, she noted. And it would usually be too late to do anything with regard to readmission.
CareMount also asks the SNFs to provide the group with the number of beds that are available on a weekly basis, as well as for partnership when its determined that a patient has to be converted to a long-term care stay.
Communication is one of the most crucial elements of the relationship between CareMount and its SNFs, all CareMount’s executives agreed. CareMount and the SNFs needed to improve processes of communication and setting up point people, Morel said.
Length of stay emerged as another sticking point. The ACO’s average length of stay in SNFs had been about 31 days, which was quite high compared to the rest of the country.
“Average length of stay in your well-managed networks is less than half that,” Morel said. “So that is an area that we’ve tried to help them to work on.”
Skilled nursing providers have been under pressure for years to bring down length of stay, and have at times protested that managed care organizations of all stripes set unreasonable expectations.
However, given that length of stay is directly tied to an ACO’s costs, if SNFs want to make themselves true partners, they have to keep both outcomes and expenses in mind. And SNFs are in a good position for transformation in health care overall if they’re focused on these dual objectives, Kamen told SNN.
“Medicine is moving towards value,” Morel said. “And I think they need to look at providing the highest quality care for the lowest cost.”