Disclaimer

Foreword

Preface

Acknowledgments

About the Author

Introduction

Chapter 1 Background and the Path to ACOs

Introduction

History of Accountable Care

History of Managed Care

ACO: Another Name for Managed Competition

The Path to Accountable Care Organizations

Setting the Stage for ACOs: An Environment Demanding Change

Chapter Summary

Endnotes

Acronyms

Chapter 2 Federal ACOs

Purpose of Accountable Care Organizations

Overview of Value-Based Purchasing

The Patient Protection and Affordable Care Act (ACA) and the Medicare Shared Savings Program

Overview and Intent of the MSSP

Related Affordable Care Act Provisions

Center for Medicare and Medicaid Innovation

Value-Based Purchasing Demonstrations

Medical Home Model

Bundling Demonstration Project

MSSP Proposed Rule

Overview of the Main Provisions of the MSSP Proposed Rule

Industry Response

Significant Changes between the MSSP Proposed and Final Rule

MSSP Final Rule

Operational Terminology

Accountable Care Organization

ACO Participant

ACO Provider/Supplier

ACO Professional

Development

Eligible Entities

Structural Requirements

Governance

Implementation

The ACO Agreement

Accountability: The Assignment of Medicare Beneficiaries

Operation

Quality and Other Reporting Requirements

Monitoring and Termination

Reimbursement

Shared Savings Payments

Subsequent ACO Models under Development

Pioneer ACO Model

Advanced Payment ACO Model Initiative

Accelerated Development Learning Sessions

Proposals for State Payors: Medicaid ACOs

Industry Feedback and Agency Response

American Hospital Association (AHA)

American Medical Group Association (AMGA)

American Medical Association (AMA)

American Academy of Family Physicians (AAFP)

America’s Health Insurance Plans (AHIP)

Physician Group Practice Demonstration Project Participants

Medicare Payment Advisory Commission

Chapter Summary

Endnotes

Chapter 3 Commercial ACOs

What Are Commercial ACOs?

Distinguishing between Federal ACOs and Commercial ACOs

Regulatory

Reimbursement

Competition

Technology

Development

Eligible Entities

Structural Requirements

Coordination of Care

Technology

Governance

Implementation

The ACO Agreement

Accountability

Operation

Quality and Other Reporting Requirements

Monitoring

Reimbursement

Fee-for-Service.

Pay-for-Performance

Bundled Payment

Partial Capitation

Full Capitation

Contents ix

Global Budget

Tiered Payment Models

Shared Savings and Losses

Chapter Summary

Endnotes

Chapter 4 Hypothetical Models for the Development and Operation of ACOs

Structural Features

Federal ACOs

Commercial ACOs

Traditional Structure

Single Healthcare Organization Structure

Transition Challenges

Operational Challenges

Federal ACOs

Commercial ACOs

Competitive Marketplace Challenges

Federal ACOs

Commercial ACOs

Chapter Summary

Endnotes

Chapter 5 Impact of ACOs on the Healthcare Industry: Addressing Industry Concern

Regulatory Concerns

Impact on Providers

Antikickback Laws

Chapter 6 Capital Finance Considerations for the Development and Operation of ACOs

Background

History of Healthcare Financing

The Financial Crisis: 2007–2009

Chapter 7 Financial Feasibility Analysis for ACO Investments

Case Studies: Real Investments of Capital

The Investment Decision

Value Metrics

Cash Flow Analysis

Feasibility Analysis

Payback Period and Discounted Payback Period Methods

AARR Method

Net Present Value

Internal Rate of Return

Further Feasibility Analysis

Chapter Summary

Endnotes

Chapter 8 Considerations of Value for the Positive Externalities of ACOs

Defining Value

Value to SOCIETY

Monetary Value

Cost of Healthcare

Productivity Measures

Nonmonetary Value

Chapter 9 The Role of the Healthcare Consultant

Overview

Economic and Financial Consulting Services Relevant to ACOs

Episodic Services

Continuity Services

Value Metric Services

Financial Feasibility Services

Valuation (Financial Appraisal) Services: Establishing Fair Market Value and Commercial Reasonableness

Selecting and Working with Consultants

Consultant Skills and the Body of Knowledge

Organizational and Strategic Capabilities

The Consulting Process

Data Gathering & Research

The Consulting Analytical Process

Technical Tools

Reporting of Consulting Engagement Deliverables

Chapter Summary

Endnotes

Conclusion

Epilogue

Bibliography

Regulatory Reimbursement

Competition

Technology

Glossary

Literature Review

Index