For Providers
What is the Pioneer ACO Model?
The Pioneer ACO Model is a new initiative established by the Centers for
Medicare and Medicaid Services (CMS), designed to test how moving experienced organizations
to population-based payment arrangements can achieve cost savings across the ACO,
which will improve health outcomes for Medicare beneficiaries. Medicare intends
to contract with 32 ACOs across the country under a demonstration project for Medicare
beneficiaries (separate from Medicare Advantage plans). Banner Health Networks has
responded to CMS with an interest in participating in this project, which would
begin in 2012 with a subset of our Phoenix-area Banner network comprised of a portion
of BPHO, AIP and BMG providers to be accountable for the quality, cost and overall
care of traditional fee-for-service Medicare beneficiaries who may be aligned to
it.
How can providers participate in Banner Health Networks?
Providers must be a part of one of the networks that compose Banner Health
Networks – AIP, BPHO or BMG. The initial network for 2012 was submitted
to CMS as a subset of the entire BHN physician network based upon several criteria
and a willingness of the provider to participate. The Pioneer ACO models allows
for additional providers to be added on an annual calendar year basis.
BHN is anticipating significantly expanding the provider network for 2013.
Is there a term clause?
Providers that initially agreed to participate under the Pioneer Model as a member
of the Banner Health Networks can opt-out of the Pioneer ACO Model according to the
terms of their participation agreements.
Why Banner Health Networks?
The current health care system is too costly and unsustainable because
of escalating cost and declining reimbursement for care provided. Providers currently
predominately operate under a volume-based, fee-for-service model, which means the
more care and services they provide, the more they are rewarded. In order
to ensure our continued success, however, providers must shift to a new value-based
model of population health management, while also balancing the present volume-based
model.
Operating under this new model will essentially allow the BHN particpants to align a comprehensive network of providers (hospitals, primary care and specialty physicians, post-acute, home long-term care, ancillary providers, pharmacy, public health agencies, hospice and wellness programs) with payers who together have accountability for managing and improving the health and close coordination of patient care of the members within a defined group or population.
What Is Reimbursement Like?
Until at least 1/1/14, Medicare will continue to pay the provider directly
at the same Medicare reimbursement rates that exist today. Unlike today, participating
providers in this partnership will also be eligible for upside, shared-savings that
could enable them to be paid better rates than traditional Medicare.
Why should physicians participate? Why is it beneficial?
There are a number of reasons a provider should consider becoming part
of the Banner Health Networks including:
- Opportunities to improve reimbursement rates, compared with the traditional Medicare reimbursement model for providing cost-effective, evidence-based health care.
- Movement of CMS and virtually all insurance plans from transaction-based, fee-for-service reimbursement methodologies to outcomes-based incentive reimbursements tied to the health of the covered population.
- Early adoption of these new models will enable the providers to be much better positioned for other similar arrangements and influence how those models function.
- Focusing more on population health management, quality improvements, access, patient satisfaction, which are all features of this model should prove to be rewarding to the patient population served within this model and allow providers to be better positioned to retain and grow their patient base.
- Rewards providers for providing quality care.
Are beneficiaries required to participate in the Pioneer ACO Model?
No. Beneficiaries will have the option to receive services from providers
outside the ACO at any time and ACOs are forbidden from restricting which providers
a beneficiary may seek care from. Beneficiaries participating will be surveyed by
CMS to ensure they are receiving high quality care. In addition, beneficiaries are
permitted to opt out of data sharing with the Pioneer ACO.