ACOs want increased participation of long-term and post-acute care providers

Accountable care organizations are calling on the feds to increase participation of long-term and post-acute care providers in ACOs and to better incorporate episodic-based payments.

The recently released white paper highlights ways the ACO REACH Model and Medicare Shared Savings Program (MSSP) can be utilized to grow participation.

"If CMS is to achieve its goal of having all Medicare beneficiaries in an accountable care relationship by 2030, then it must take steps to better include provider types less represented in ACOs, including SNFs,” said National Association of ACOs (NAACOS) Senior Vice President of Government Affairs Aisha Pittman. “We hope our recommendations spark attention to this area, because patients served by LTPAC providers deserve the higher quality, lower cost care we know value-based care delivers.”

Stakeholders said the long-term nursing facility population should be removed from the MSSP and other models, since many community-based providers no longer provide primary care to these beneficiaries.

Short-stay nursing facility populations receive care in short-term rehab facilities, while long-stay populations are institutionalized and receive care from providers. Long-stay facilities receive funding from Medicaid and private insurance, versus short-stay facilities that receive funding from traditional Medicare, Medicare Advantage and commercial plans.

ACOs also want the Centers for Medicare & Medicaid Services (CMS) to use the same risk adjustment model tested in ACO REACH for the nursing facility population. They call on CMS to "ensure historical references are accurate" for new institutions for any changes to the risk adjustment model.

As for quality measures, CMS is urged to better prioritize metrics that establish "superior care transitions and discharge planning." Roundtable participants believe data should be shared regularly from CMS, allowing for a feedback loop for updates or corrections. They want CMS to flag beneficiaries prospectively attributed to other ACOs or shared savings programs. Additionally, the agency is asked to fund data infrastructure for nursing facilities

“There is a tremendous opportunity for long term and post-acute care providers to lead the way with these value-based programs,” said Nisha Hammel, American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) vice president of population health management.

Participants also vouched for voluntary episode-based payment models. They said models may need to be designed for skilled nursing facility (SNF) providers nested inside ACOs, based on provider type or clinical conditions, to ensure targeted approaches.

Any nested bundle should try to enhance care coordination across settings and improve discharge planning, enhance quality of care, apply to many specialty provider types, account for risks faced by rural value-based care providers, include a dynamic target pricing mechanism based on live data and include population-tailored benefit enhancements, among other requests.

On who would administer the bundle: "One approach is to have the ACO itself administer the bundle. Under this approach, the ACO would enter into a contract with the SNF, bypassing CMS altogether," the white paper said. "Under a second approach, CMS would administer the bundle, bringing the ACO and SNF together and providing oversight and guardrails around the arrangement."

The roundtable did not come to a consensus as to which approach would be preferred. Participants said it might make sense for SNFs to accrue most savings or losses but noted ACOs should still share in the outcome.

Less than 2,000 SNFs participate in ACOs, with nearly 70% of ACOs having no SNF representation, a news release said. The stakeholders said current ACO models "do not align well" with LTPAC providers despite the savings it can spur.

A 2023 analysis from MedPAC found that Medicare spent nearly $57 billion on post-acute care.

The findings come as a result of a roundtable convened by NAACOS, AHCA and NCAL in August 2023. Roundtable participants included America's Health Insurance Plans, the American Hospital Association, Families USA, Premier, Special Needs Plan Alliance and VillageMD.