Payers

CCMS-ACO will embed Coordinated Care, Transitional and Chronic Care Management (TCM & CCM) into maintaining the payer's population's diseases managed by the Primary Care Physician with the help of a robust Health IT platform to provide Best Care and drive associated benchmark costs below their mean. CCMS-ACO will also bring a new level of reporting that is not currently the norm for payers to see from commercial ACO.

 

  

Accountable Care Organizations (ACOs) are often touted as the healthcare delivery model of the future. Though CMS’ Medicare Shared Savings Program receives the most attention from analysts and the media, the real direction of ACOs is being determined behind the scenes in the private sector. Commercial ACOs cover millions of lives but are often overlooked because they have no public reporting requirements, their existence is not always announced, and rarely do providers or insurers give a complete account of their performance unless one does especially well. However, they encounter some of the same obstacles: managing the  of value-based reimbursement, developing effective physician leadership, and determining the best way to use technology. 

Despite the lack of some data, enough information exists to define the scope of commercial ACOs operations today. According to a recent Leavitt Partners analysis, shared risk and shared savings agreements between providers and commercial insurers covered 17.2 million lives in April 2016, over twice as many as Medicare and Medicare ACOs combined. Definitive Healthcare currently counts over 500 commercial agreements, nearly 400 of which are directed by one of five major insurers. In terms of general structure, commercial payers usually provide claims data, analytics capabilities, and sometimes care managers to help patients navigate their care options, while providers are in charge of clinical operations. Many also emulate the MSSP model, paying providers for services normally and comparing costs to a target benchmark each year.

Image Credit: Definitive Healthcare

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