Best practices, legislative priorities and SNFs: 4 key takeaways from the NAACOS spring conference

The National Association of ACOs (NAACOS) hosted a spring conference last week, with sessions on post-acute care, fraud, implementation best practices, health equity and legislative priorities.

CMS officials, industry executives and independent experts gave their thoughts on where the industry is headed and where improvements are needed in the accountable care world.

Here are four takeaways from the event:

1. CMS is monitoring ACOs’ concerns over DME fraud

Urinary catheter fraud uncovered by NAACOS earlier this year could severely impact organizations’ finances, effecting benchmark payments and long-term stability.

CMS officials said they are grateful NAACOS brought issues of fraud to light, and a new approach for “anomalous billing” will be presented in the upcoming weeks for the Medicare Shared Savings Program (MSSP) and ACO REACH.

However, Center for Medicare and Medicaid Innovation (CMMI) Director Liz Fowler said it’s possible rises in cost are primarily from waste, not fraud.

2. Best practices playbook unveiled with no health equity chapter

The American Medical Association, AHIP and NAACOS released a best practices playbook on value-based care payments, the second installment of its collaborative playbook series.

The first edition centered around value-based care arrangements.

“This iteration of the playbook synthesizes what we’ve learned over the last decade plus, so that payers, physicians, hospitals, and ACOs can implement payment and delivery models that improve outcomes and lowers costs.,” said outgoing NAACOS President and CEO Clif Gaus in a statement.

Voluntary best practices are sorted by payment attribution, benchmarking, risk adjustment, quality performance impact on payment, levels of financial risk, payment timing and accuracy and incentivizing for value-based care practice participant performance.

ACOs are encouraged to stick benchmarking targets through a 20-year model, said Travis Broome, senior vice president for policy and economics. Organizations should also be aware of whether its payment methodologies is accepting insurance risk.

The playbook does not explicitly include policy recommendations (choosing to focus on actionable information) or a chapter on health equity. That is intentional.

“Some people say we should have an equity model,” said Danielle Lloyd, senior vice president of market innovations and quality initiatives at AHIP. “The way we landed was infusing equity throughout … the different domains.”

“To me, that’s always a risky decision,” said Broome, noting it’s easy to not ask the uncomfortable questions if a chapter isn’t dedicated to the topic. “It should make it a lot harder to do your playbook if you’re infusing equity into every aspect.”

The panelists want future collaboration to address quality measures and provider directories.

3. Lame duck season is here

Perhaps it’s no surprise, but NAACOS regulatory experts don’t foresee healthcare legislation getting passed before the November election.

Gridlock will likely take hold and not let go in what has already been a historically unproductive Congress, said NAACOS Director of Legislative Affairs Robert Daley.

“It’s going to be a very turbulent time,” he said. “It’s actually a complete replay, it seems, of 2020. Anytime you have a presidential election year, it's really going to take a lot of the oxygen out of the room.”

If President Trump were to retake the White House, federal healthcare policy would change drastically. But even if President Biden wins reelection, there is still uncertainty.

Last week, reports indicated Department of Health and Human Services Secretary Xavier Becerra could leave the cabinet to run for governor of California.

“We see a lot of turnover administration between the first or the second term,” said NAACOS Director of Communications and Regulatory Affairs David Pittman.

That doesn’t mean the group won’t be advocating behind the scenes for certain changes.

The group is focused on extending advanced APM incentives, a provision that has been extended at a lower percentage each year. In Congress’ pursuit of spending less money on healthcare, it re-upped the advanced APM incentive at a rate of just 1.88%.

NAACOS also wants to build consensus on long-term legislation reform for the Medicare Access and CHIP Reauthorization Act (MACRA), CMMI reform and telehealth.

ACO REACH garnered words of support during the conference as well, pushing back against critics that said the model isn’t working.

“We inevitably get someone on our LinkedIn page saying, ‘well, ACOs only save this much money. That’s a drop in the bucket of Medicare spending,’” said Aisha Pittman, NAACOS senior vice president of government affairs. “I think what’s important to remember is that the overall trend of spending is going down. We know that value is working.”

She cited a Congressional Budget Office report showing that federal health spending projects were 9% lower from 2010 to 2020 than originally anticipated.

Pittman added that the Biden administration has been less receptive to moving toward digital quality measures. She hopes pilot testing around these approaches will take place, though CMS is restricted by statutory limitations.

4. More partnerships needed between ACOs and skilled nursing facilities

Skilled nursing facilities (SNFs) face a range of issues, not least of which is too few ACOs partner with post-acute facilities, experts said.

They said there is a disconnect between SNF leaders and ACOs for various reasons.

“They don’t think about ACOs as a partner, for the most part,” said Ray Thivierge, a healthcare strategist and consultant. “Most of them see ACOs as a threat.”

Fewer than 10% of SNFs are represented within an ACO, he added. Less than 70% of ACOs have SNF partners.

These days, the elderly population has the ability to stay in assisted living facilities or retirement communities and take advantage of at-home care. He said nursing homes and ACOs need to align incentives and a vision so both groups are pulling in the same direction.

Nursing homes face many challenges - staffing shortages, low pay for personnel, high costs for admission, to name a few.

“I think it's really important for ACOs to find high quality nursing homes to work with them,” said Rob Mechanic, executive director for the Institute for Accountable Care.

As policymakers and legislators transition healthcare to value-based care, experts on the panel warned SNFs they must adapt. Thivierge said nine in 10 SNFs will need to transition reimbursement scenarios and care delivery modalities in the next five years.

Reading the Centers for Medicare & Medicaid Services (CMS) tea leaves shows that the feds are funding more and more initiatives pushing patients to home-based care and fewer hospitalizations, said Dana Strauss, senior director of government affairs for CVS Health.

“We are on the precipice of a significant shift of care into the home,” she said. “SNFs have to believe first that there is an existential threat to where their referrals are coming from.”

She said ACOs should partner with SNFs as a preferred provider, something certain SNFs already do.