Avalere Health
An Inovalon Company
Insights

Mar 31, 2015

New Trends and Analysis for ACO Participants

The recent addition of 89 Accountable Care Organizations (ACOs) to the Medicare Shared Savings Program (MSSP) coupled with HHS’ January announcement on transitions to value-based care highlight payment and delivery innovation’s gathering momentum in federal health reform.

In addition, private sector ACO activity continues to march forward; Avalere estimates that private payers have launched more than 230 ACOs across the country. However, stakeholder overemphasis on national accountable care trends places organizations at risk of leaving 50 opportunities in their blind spot: individual states.

Avalere analysis shows that 28 states and DC have decided to expand their Medicaid programs, identifying an additional four states as candidates to watch in the months ahead. As the number of Medicaid beneficiaries grow, so too are states’ appetites for population health innovation, often manifesting itself in the form of Medicaid ACOs. According to Avalere tracking and analysis, 12 states have already launched 59 Medicaid ACOs, with another six states in planning stages or testing alternative accountable care models. 

Thus far, Medicaid payment and delivery innovation has been mostly concentrated in those states implementing ACA expansion, as 13 of the 18 states that have launched or plan to launch Medicaid ACOs are either already Medicaid expansion states or Avalere identified states to watch. Still, the Medicaid ACO concept is also permeating throughout the United States in areas that find Medicaid expansion unpalatable, as five non-expansion states (AL, FL, LA, ME, NC) already host 7 Medicaid ACOs and have plans for more. 

If engagement with federal reforms continues to be a harbinger of state-level innovation and perhaps adoption of Medicaid ACOs, stakeholders may find insights through the State Innovation Model awards. There are currently 8 states (AZ, KY, MD, NV, NH, NM, PA, WV) and DC that are undergoing Medicaid expansion and have not yet pursued Medicaid ACOs, but are currently in the model design stage of the State Innovation Model awards. Each of these states represents unique opportunities to influence the future of accountable population health management for America’s most vulnerable newly covered populations. 

As these state-based ACO initiatives mature, Avalere will be tracking them to determine whether and how they look like MSSP, the Pioneer ACO program, private sector models or something else entirely. Some of the questions we’ll be asking include: 

  • Are ACOs held accountable for a global budget or are certain costs excluded (e.g., outpatient drug costs, such as in MSSP)?
  • How are states establishing benchmarking for calculating cost savings?

  • To what extent are states holding providers accountable for two-sided risk (share in losses as well as savings)?
  • Are states primarily contracting with hospital-based delivery systems or – like MSSP – establishing relationships with physician-led ACOs as well?
  • To what extent do Medicaid ACO regulations affect ACOs’ ability to effectively engage beneficiaries?
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