On the day of President Donald Trump’s inauguration, Medicare announced Carilion Clinic was selected as one of 45 health systems across the country to participate in its latest program that rewards doctors and hospitals for helping elderly people manage chronic illnesses.
The Next Generation Affordable Care Organization payment model could disappear if the Affordable Care Act is repealed, but the program will remain at Carilion.
Donna Littlepage, senior vice president of accountable care strategies, said Carilion since 2009 has been shifting toward coordinated care and would continue to do so regardless of whether the government encourages it.
Medicare has been moving away from the traditional method of paying hospitals and doctors for each exam and test performed. Under that method, payment was made regardless of whether a patient’s health improved or deteriorated.
With Accountable Care Organizations, Medicare has moved toward paying for the quality, rather than quantity, of care. Providers are paid a set amount to care for patients with the idea that they’ll better manage chronic illnesses so patients’ conditions don’t worsen and require costly tests, procedures and hospitalizations.
Littlepage said the initial Medicare ACO program had flaws; for example, it didn’t account for patients who developed cancer unrelated to their managed care, so the ACO would be penalized for illnesses beyond its control.
The Next Generation program corrects this, and it also brings the ability for greater financial risk and reward depending on the health outcomes of patients. Carilion projects it will be on the favorable side of the ledger, but Littlepage said it will continually monitor the program.
Some Carilion patients already are working with coordinated-care nurses. Littlepage said Medicare has identified between 45,000 and 50,000 patients within Carilion’s system who might qualify for the program.
To identify which patients would benefit the most from coordinated care, Carilion has contracted with a firm to analyze billing and patient records. A team of nurses, dietitians, social workers, pharmacists and behavioral health providers will work with patients and their primary care physicians to better manage diseases and prevent costly complications.
Carilion has already started doing this, but the new Medicare program will allow it to reach more patients faster than if it were doing it alone, she said.
The program also allows for payments for tele-health services, more choices in providing home visits after hospital discharges, and the ability to admit patients to nursing homes without first undergoing a three-day stay in the hospital.
Carilion is the only health system in Virginia participating in the Next Generation ACO program.
Tom Price, Trump’s nominee for health and human services secretary, has said he’s supportive of Medicare’s innovative programs, but he has also said he supports full repeal of the Affordable Care Act, which created the program.
Littlepage said Carilion would still move forward if the program disappears but at a slower pace without financial incentives to pay for the coordinated care teams.