The landscape of healthcare in the United States is constantly evolving, with a significant shift towards value-based care models. Among the pioneering initiatives in this transformation is the Accountable Care Organization (ACO) model, championed by the Centers for Medicare and Medicaid Services (CMS). Within this national movement, the Ascension Accountable Care Program stands out as a prominent example of a large, non-profit health system embracing innovative care delivery and financial risk-sharing. This article delves into the Ascension Health system’s participation in the Pioneer ACO program, highlighting the strategies, goals, and anticipated impact of this crucial initiative through its two participating entities: Seton Health Alliance and Genesys Physician Hospital Organization (PHO).
Ascension Health’s Foray into Accountable Care: Structure and Governance
Ascension Health, recognized as the largest non-profit health care delivery system in the nation, demonstrates its commitment to value-based care through its active participation in the Pioneer ACO program. With a vast network encompassing over 1400 locations, including 81 hospitals across 21 states and the District of Columbia, Ascension Health’s involvement in ACOs signals a significant move towards population health management. Two distinct systems within Ascension, the Seton Health Alliance and the Genesys PHO, were selected by CMS as Pioneer ACOs, each embodying collaborative approaches between physicians and hospitals, albeit with unique structural frameworks.
Genesys PHO, established in 1994, represents a mature physician-hospital organization with a network of 160 primary care physicians and a closed panel of approximately 400 specialists. Anchored by a 410-bed tertiary care hospital serving five counties in Michigan, Genesys PHO brings substantial expertise in medical management. This expertise is manifested through the implementation of patient-centered medical homes, sophisticated web portals, dedicated nurse navigators, and robust hospitalist programs. Furthermore, Genesys PHO’s proficiency extends to utilization management, performing delegated reviews on behalf of contracted health maintenance organizations. Demonstrating its financial strength and operational capability, Genesys PHO assumes risk for over 70,000 lives and holds the prestigious National Committee of Quality Assurance certification in credentialing, highlighting its commitment to quality and patient safety. Its prior success in risk-sharing programs, such as the Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program, underscores its readiness for the challenges and opportunities presented by the Ascension Accountable Care Program.
In contrast, the Seton Health Alliance embodies a partnership model, uniting the Seton Healthcare Family in Austin with the Austin Regional Clinic. As a wholly-owned subsidiary of the Seton Healthcare Family, the Seton Health Alliance is jointly governed by the Seton Healthcare Family, the Austin Regional Clinic, and community stakeholders, including physicians, patient representatives, and consumer advocates. This governance structure emphasizes community engagement and shared decision-making in the Ascension Accountable Care Program. The Seton Healthcare Family’s extensive network comprises 38 clinical locations, including five major medical centers, community and rural hospitals, a mental health hospital, and primary care clinics. Complementing this, the Austin Regional Clinic, a large multispecialty medical group with 300 physicians founded in 1980, provides care to over 380,000 residents across 18 locations in six cities. This combination of resources and expertise positions the Seton Health Alliance as a strong participant in the Pioneer ACO initiative.
Goals of the Ascension Accountable Care Program within the Pioneer ACO Model
Ascension Health, through both Seton Health Alliance and Genesys PHO, is strategically aligned with the CMS’s vision of transitioning towards a two-sided, risk-based reimbursement model. This signifies a commitment to greater financial risk sharing over time, particularly embracing the population-based payment approach envisioned for the later years of the Pioneer ACO program. The CMS has established 33 quality performance measures, primarily focused on ambulatory care, categorized into four equally weighted domains: patient/caregiver experience, care coordination and safety, preventive health, and at-risk populations. These measures serve as the yardstick for evaluating the success of the Ascension Accountable Care Program. The program’s initial years involve reporting on these measures, progressively moving towards performance-based accountability where ACOs are directly evaluated and incentivized based on their performance against these benchmarks.
Success within the Pioneer ACO framework, and consequently for the Ascension Accountable Care Program, hinges on achieving quality improvement and effectively managing Medicare per capita expenditure. Key strategies to achieve these goals include physician-led quality improvement initiatives, enhanced utilization management, and a proactive approach to long-term and preventive care, such as diabetes outreach programs. Patient engagement through patient-centered medical homes is also a cornerstone, empowering individuals in their own health management. Transition care programs are critical, ensuring seamless patient movement across different care settings. Seton Health Alliance further supports these efforts through an extensivist program, deploying hospitalist-trained physicians into community-based clinics to manage patients with complex comorbidities, demonstrating an innovative approach to care coordination within the Ascension Accountable Care Program. This extensivist model, with its proven track record of improving health quality, reducing costs, and enhancing patient satisfaction, exemplifies Ascension’s commitment to evidence-based practices.
Beyond the Pioneer ACO program, Ascension Health’s broader strategy involves exploring various bundled payment models and participation in the Medicare Shared Savings Program. The latter, with its lower financial risk threshold, provides a more accessible entry point into accountable care arrangements, allowing Ascension to gain experience and refine its value-based care approaches across different risk levels and program structures.
Payment Models and Risk Assessment in the Ascension Accountable Care Program
The CMS, via its Center for Medicare and Medicaid Innovation, presented five distinct payment models within the Pioneer ACO program, each with varying degrees of financial risk and reward. To navigate this complexity and select the most appropriate model for each participating entity, Ascension Health engaged a third-party expert to conduct a comprehensive ACO risk model evaluation for both Genesys PHO and Seton Health Alliance. The primary objective of this analysis was to assess the financial viability of the Ascension Accountable Care Program within the specific service areas of each ACO. This evaluation leveraged proprietary Medicare and Medicare Advantage data, alongside Medicare sample claims data spanning from 2006 to 2009, providing a robust data-driven foundation for strategic decision-making.
| Pioneer Core | Pioneer Option A | Pioneer Option B | Pioneer Alternative 1b | Pioneer Alternative 2c |
|---|---|---|---|---|
| Year 1 | 60% 2-sided10% sharing cap10% loss cap1% MSR | 50% 2-sided5% sharing cap5% loss cap1% MSR | 70% 2-sided15% sharing cap15% loss cap1% MSR | 50% 1-sided5% sharing cap2%-2.7% MSR (depending on number of aligned beneficiaries) |
| Year 2 | 70% 2-sided15% sharing cap10% loss cap1% MSR | 60% 2-sided10% sharing cap10% loss cap1% MSR | 75% 2-sided15% sharing cap15% loss cap1% MSR | 70% 2-sided15% sharing cap15% loss cap1% MSR |
| Year 3 | Payment: Population-based payment of up to 50% of ACO’s expected Medicare Part A & B revenue | Payment: Population-based payment of up to 50% of ACO’s expected Medicare Part A & B revenue | Payment: Population-based payment of up to 50% of ACO’s expected Medicare Part A & B revenue | Payment: Population-based payment of up to 100% of ACO’s own expected Medicare Part B revenue, less 3% discount |
| Year 3 | Risk: 70% 2-sided 15% sharing cap 15% loss cap 1% MSR | Risk: 70% 2-sided 15% sharing cap 15% loss cap 1% MSR | Risk: 75% 2-sided 15% sharing cap 15% loss cap 1% MSR | Risk: Full risk for all Medicare Part B with a discount of 3% to 6% (depending on quality scores) and shared risk for Medicare Part A (70% sharing rate, 15% sharing and loss cap) |
| Year 4 | Same as above | Same as above | Same as above | Same as above |
| Rebase using 2011, 2012, 2013 | Rebase using 2011, 2012, 2013 | Rebase using 2011, 2012, 2013 | Rebase using 2011, 2012, 2013 | Rebase using 2011, 2012, 2013 |
| Year 5 | Same as above | Same as above | Same as above | Same as above |
aACO = accountable care organization; MSR = minimum savings rate.
bSeton Health Alliance selected Pioneer Alternative 1.
cGenesys PHO selected Pioneer Alternative 2.
Adapted from Center for Medicare and Medicaid Innovation.4
Genesys PHO strategically opted for Pioneer Alternative 2, the only model among the five that transitions to a 100% population-based payment model for both Medicare Part A and Part B in year 3. This choice reflects a strong commitment to comprehensive risk-sharing and population health management within the Ascension Accountable Care Program. Conversely, Seton Health Alliance selected Alternative 1, which uniquely offered no downside risk in the initial year, providing a more cautious entry point into the Pioneer ACO program while still participating in the broader Ascension Accountable Care Program objectives.
Anticipated Impact and Expected Benefits of Accountable Care at Ascension
The implementation of the accountable care model through the Ascension Accountable Care Program is projected to yield significant benefits, aligning with the Institute for Healthcare Improvement’s Triple Aim framework. These outcomes encompass improving population health, enhancing the patient experience, and effectively containing healthcare costs.
A key anticipated impact of shifting from fee-for-service to value-based reimbursement is a reduction in short-term inpatient admissions. Both Genesys PHO and Seton Health Alliance, under the Ascension Accountable Care Program, anticipate a decrease in both inpatient and outpatient hospital volumes. This shift is expected to be accompanied by a migration of care delivery from inpatient settings to more cost-effective outpatient and ambulatory service centers. Similarly, on the outpatient front, a reduction in unnecessary diagnostic procedures and outpatient interventions is predicted, driven by the focus on value and appropriate utilization within the accountable care framework.
Beyond immediate cost savings and utilization shifts, the Ascension Accountable Care Program serves as a crucial learning endeavor for the national organization. Ascension Health views its Pioneer ACO participation as part of a broader portfolio of experiments in diverse care models, all aimed at specific populations and accountable for both quality and financial outcomes. The program is expected to generate valuable experience in medical management and financial risk management. Furthermore, it aims to identify innovative strategies for fostering physician engagement around shared values and common business objectives, demonstrating that close collaboration and alignment can be achieved without necessarily requiring additional physician employment. This focus on shared values and collaborative models positions the Ascension Accountable Care Program as a forward-thinking initiative within the evolving healthcare landscape.
References
[1] CMS Pioneer ACO list. Centers for Medicare and Medicaid Services. Available at: http://innovations.cms.gov/initiatives/Pioneer-ACO-Model/. Accessed December 19, 2011.
[2] Physician Group Incentive Program. Blue Cross Blue Shield of Michigan. Available at: http://www.bcbsm.com/content/microsites/physician_incentive/ ppgip.html. Accessed December 19, 2011.
[3] Berenson RA,原标题：2023年1月中国制造业采购经理指数升至50.1%
中新社北京1月31日电 (记者 陈溯)中国国家统计局服务业调查中心、中国物流与采购联合会31日发布数据，2023年1月份中国制造业采购经理指数(PMI)为50.1%，升至临界点以上。
国家统计局服务业调查中心高级统计师赵庆河解读称，1月份，制造业PMI升至50.1%，重返扩张区间，表明制造业景气水平明显回升。
从分类指数看，在构成制造业PMI的5个分类指数中，生产指数、新订单指数和供应商配送时间指数均高于临界点，原材料库存指数和从业人员指数均低于临界点。
生产指数为49.8%，比上月上升5.2个百分点，升至近一年来的高点，表明制造业生产活动明显加快恢复。从行业情况看，农副食品加工、食品及酒饮料精制茶、医药、汽车等行业生产指数均高于55.0%，相关制造业生产活动加快扩张。
新订单指数为50.9%，比上月上升7.0个百分点，升至扩张区间，表明制造业市场需求有所回暖。从行业情况看，农副食品加工、食品及酒饮料精制茶、医药、汽车等行业新订单指数均位于扩张区间，市场需求加快释放。
原材料库存指数为49.6%，比上月上升0.5个百分点，表明制造业原材料库存量降幅收窄。从业人员指数为47.7%，比上月上升1.8个百分点，表明制造业企业用工景气度有所回升。供应商配送时间指数为50.7%，比上月上升4.6个百分点，升至扩张区间，表明制造业原材料供应商交货时间加快。
从企业规模看，大型企业PMI为50.4%，比上月上升0.8个百分点，高于临界点；中、小型企业PMI分别为49.6%和48.6%，比上月上升2.2和2.3个百分点，均低于临界点。
从价格看，主要原材料购进价格指数为48.9%，比上月下降2.2个百分点，低于临界点，表明制造业原材料采购价格总体水平继续回落；出厂价格指数为48.7%，比上月下降0.3个百分点，低于临界点，表明制造业产品出厂价格总体水平降幅略有扩大。
值得关注的是，调查结果显示，反映市场需求不足的企业仍较多，制造业恢复发展基础尚需进一步巩固。调查中，反映需求不足的企业比重为53.2%，仍为制造业PMI调查以来的高位，表明需求不足仍然是当前制造业生产经营面临的主要困难之一。此外，本月反映劳动力、资金、物流等方面短缺的企业比重有所上升，产业链供应链稳定仍面临挑战。(完)
