3 MATERIAL Y MÉTODOS
1. Análisis de la utilización de la angiografía coronaria mediante tomografía computarizada multidetector en el mundo real
“One-sided” or Asymmetric Model
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Continue operating under current insurance contracts and coverage models (e.g., FFS reimbursement)•
Provider groups have no risk for losses if spending exceeds budget benchmarks•
Provider groups receive relatively modest percentage of any earned savings due to limited risk•
Most incremental approach with least barriers to entry•
Minimal requirements for health IT infrastructure and governance structure•
Limited to no experience with alternative to FFS payments•
Attractive to new entities, risk- adverse providers, or entities with limited organizational capacity or experience coordinating care across providers“Two-sided” or Symmetric Model
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Payment still predominantly FFS, but may include some alternative systems such as bundled payments•
Provider groups are at risk for losses if spending exceeds projected benchmarks•
Increased incentive for providers to decrease costs due to risk of losses•
Provider groups receive higher percentage of any earned shared savings in line with increased risk•
Attractive to providers with some health IT infrastructure, care coordination capability and demonstrated track record managing carePartial Capitation Model
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Provider groups receive mix of FFS and prospective fixed payment•
Provider groups share costs if expenditures exceed the projected benchmarks; may even have first dollar risk under a global budget model•
If successful at meeting budget and performance targets, greater financial incentives•
If ACO exceeds target, more risk means greater financial downside•
Only appropriate for providers with robust health ITinfrastructure, demonstrated track record in finances and quality
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May need to comply with state regulatory oversight to take on financial riskIdeally, an ACO will transition over time to implement payment models with increasingly more risk, resulting in the ability to retain a higher percentage of shared savings for being more accountable for cost and quality, as shown in Exhibit 3.12. As organizations grow more comfortable managing risk and become more clinically integrated through new care strategies and more sophisticated health IT, they can progress from a “one-sided” payment model (Level 1) to a “two-sided” payment model (Level 2) where an organization is liable to share in the costs if their spending exceeds their projected benchmarks. Once an ACO becomes experienced and comfortable managing the added risk of a
symmetric payment model, they could then advance to a partially capitated payment model, where some services remain on a FFS reimbursement basis, while others are reimbursed by a fixed amount per patient. For example, an ACO could received a pre-paid risk-adjusted capitated amount to cover all ambulatory care services for its ACO patients, and then have a bonus/withhold payment (i.e., a shared-savings model) based on the traditional discharge level reimbursement rates and spending targets for their inpatient services. Progressively moving towards a payment model that accepts more risk will help further incentivize an ACO to be more accountable for the cost and quality of their provided care.
Regardless of the payment model level an ACO is operating in, a necessary step to any financial performance model is to calculate the actual expenditures incurred during the financial performance period. In our illustrative example below, we define the financial performance period as a 12-month period. The period should be long enough to obtain a large enough sample of claims in order to estimate the representative spending amounts. Periods longer than a year run the risk of displacing the financial incentive from the time when services are being performed.
The methodology for calculating the actual
spending amount is similar to the above discussion on calculating the baseline incurred claims. It may be necessary to adjust the data for anomalies such as high-cost claimants. Also, it may be necessary to determine if there has been a shift in the risk profile of the population.
Once the actual spending amount has been calculated, and assuming quality benchmarks are met or exceeded, a comparison to the benchmark spending would determine if the ACO is eligible for the bonus payments. For incentive payment purposes, the comparison between the actual and the spending benchmark is performed on the aggregate claims level, not by the service category level.
Three key features to consider when formulating the bonus payments are (1) the use of a savings threshold, (2) the percentage of the savings to be shared, and (3) whether it should accept an asymmetric or symmetric risk model. These features can essentially be used as tools to balance the levels of risk that providers and payers are prepared to take in their ACO efforts.
Savings Threshold
In Exhibit 3.13 below, the savings threshold is two percent, meaning that financial performance bonuses are only distributed if the actual spending growth is lower than the projected spending growth by more than two percent. The target – or the benchmark spending growth – is therefore calculated as the projected spending growth less two percent.
Small fluctuations in actual spending amounts are to be expected. The use of the two percent savings threshold is meant to avoid making bonus payments for savings that essentially happen by chance. Thresholds can also be used in two-sided models to protect providers from financial risk against random losses.
ACOs may want to consider setting the level of the threshold as a factor of the size of the ACO membership. For example, smaller ACOs are more susceptible to larger variation and therefore a higher threshold, such as four percent, may be more appropriate. In fact, ACA establishes a minimum Medicare beneficiary panel of 5,000 for ACO participation in the Shared Savings program beginning in 2012. The greater the population size, the less variation that would be expected and the more predictable spending becomes, so a smaller threshold would be required.
The level of the threshold should also vary with the level of risk that the providers are willing to take. For instance, under a Level 3 global budget approach, providers may participate in first-dollar savings, as well as first-dollar losses.