There are nine states with accountable care organizations (ACOs) – Colorado, Iowa, Illinois, Maine, Minnesota, New Jersey, Oregon, Utah, and Vermont. But as is true with state Medicaid programs, each state’s ACO model has wide differences. As I wrote about last week in Understanding The Two Medicaid ACO Models, there are two basic models – the traditional shared savings model and the risk-based model. The traditional shared savings model modifies the Medicare Shared Savings Program and the risk-based model is an ACO-managed care hybrid.
But the differences in ACOs don’t end there. There are a number of different variables that make each Medicaid ACO initiative unique. So when you’re evaluating a Medicaid ACO initiative in your state, I would be sure to consider all the factors that shape the model, including: populations covered, population assignment, provider participation rules, ACO flexibility, and the range of risk sharing.
Populations Covered – Under the traditional shared savings model, nearly all Medicaid populations are covered, except for dual eligibles and those receiving partial benefits. Iowa is the exception to this rule, where ACOs only cover the Medicaid expansion population at this time. Under the risk-based model, the populations covered vary greatly. In Oregon and Utah, the ACOs are covering the majority of the Medicaid population including dual eligibles. While Illinois’s ACOs cover very different populations depending on their contracts – Illinois operates separate programs for the aged, blind, and disabled population and the children/caretaker relative population.
Population Assignment – Under the traditional shared savings model, beneficiaries are generally attributed by determining whether or not they received primary care services from a provider organization participating in the ACO. Most states under the traditional shared savings model attribute beneficiaries retrospectively. This is similar to the Medicare ACO attribution model (see In “Accountable Care”, Who Is Accountable For What Consumer? and Medicare Shared Savings Program Shared Savings & Losses & Assignment Methodology Specifications). The challenge of retrospective assignment is that the ACO managers do not know the exact population they are managing until after the performance period. Under the risk-based model, beneficiaries are either assigned or choose to receive care from the ACO. This means the ACO knows exactly what population they are providing care to up front.
Participating Provider Rules – Under the traditional shared savings model, ACOs are always comprised solely of provider organizations, although the types of included provider organizations may vary. For example, Maine requires that each ACO have at least one behavioral health provider, one chronic condition provider, and one developmental disability provider, while Vermont only includes primary care providers. Under the risk-based model, ACOs are generally comprised of health plans and provider organizations, sometimes working together and sometimes each operating their own ACO. In Illinois, for example, Accountable Care Entities are groups of providers. While in Utah, ACOs are health plans or health plan/hospital partnerships.
ACO Flexibility – Under the traditional shared savings model, ACOs are given choice in the services included in their total cost of care benchmark, what quality measures they will report, and are even sometimes able to choose their own model. For example in New Jersey, ACOs actually propose their own ACO model. In Vermont and Maine, ACOs can add optional services to their total cost of care benchmark, such as long-term services and supports. Under the risk-based model ACOs act as the primary delivery system for Medicaid beneficiaries and therefore CMS must approve the model. This leaves almost no flexibility and all aspects are set by the state.
Financial Risk – Under the traditional shared savings models, ACOs only take on a small degree of risk. Some are not liable for shared losses if the ACO exceeds the target benchmark and in cases where the ACO is liable for shared losses, they are only responsible for a portion of the losses. Under the risk-based model, ACOs are capitated and therefore assume 100% of the risk associated with caring for a population.
For an in-depth analysis of each state’s ACO model, including how beneficiaries are attributed, what provider organizations are eligible to participate, how financial performance is calculated, how quality performance is calculated, and the results of each model, check out our report: What Are The Different Performance & Reimbursement Models For ACOS?: An OPEN MINDS Market Intelligence Report. The report answers a number of questions including:
- What Are The Different Medicaid ACO Models?
- What Are The Key Features Of The Medicaid ACO Models?
- What Is The Colorado ACO Model?
- What Is The Illinois ACO Model?
- What Is The Maine ACO Model?
- What Is The Minnesota ACO Model?
- What Is The New Jersey ACO Model?
- What Is The Oregon ACO Model?
- What Is The Utah ACO Model?
- What Is The Vermont ACO Model?
The report is free to all OPEN MINDS Circle premium members, and can be purchased in the OPEN MINDS e-Store for $495.