A House Divided Against Itself Cannot Stand: Introducing the Medicare-Medicaid ACO Model


According to the Kaiser Family Foundation, about 9 million people in the United States are covered by both Medicare and Medicaid. These dual-eligible beneficiaries have complex, high risk, and often costly healthcare needs. Dual-eligibles are more likely to use a range of medical services, including primary care, emergency room care, behavioral health, and long-term supports and services. This presents a challenge for providers who must manage these high-risk individuals with multiple conditions across many healthcare providers and both Medicare and Medicaid insurance. In addition, many times investments in long-term care coordination by state Medicaid programs result in fewer hospitalizations and better health for patients, but the savings are realized by Medicare instead of Medicaid. This provides little incentive for state Medicaid programs to make the investment.

Because of the complexity and cost, states and healthcare providers have experimented with approaches that can realign these incentives and improve care. And now CMS has announced they are getting involved too. On December 15, 2016, the Centers for Medicare and Medicaid Services (CMS) announced they are creating a new ACO model to serve dual-eligible beneficiaries. According to CMS Acting Principal Deputy Administrator Patrick Conway, the goal of the program is to improve care coordination for dual-eligibiles, “allowing providers to focus more on providing care for their patients rather than administrative work.”

The Medicare-Medicaid Model builds on the Medicare Shared Savings Program, in which groups of providers take on accountability for the Medicare costs and quality of care for Medicare patients. Through the Medicare-Medicaid ACO Model, CMS intends to partner with interested states to offer new and existing Shared Savings Program ACOs in those states the opportunity to take on accountability for both Medicare and Medicaid beneficiaries. To date, CMS has rolled out several Medicare ACO initiatives, and at least 10 states have also rolled out Medicaid ACOs. Until now, however, ACOs have not specifically served dual-eligible beneficiaries.

The goal of Medicare-Medicaid ACOs is to achieve the Triple Aim of healthcare: enhancing the patient experience of care, improving the health of the population, and reducing the per capita cost of care. If Medicare-Medicaid ACOs generate Medicare savings for their Medicare-Medicaid enrollees, states (as well as the Medicare-Medicaid ACO) may be eligible to share in those savings with CMS. This realignment of payment incentives provides a great opportunity for states to invest in whole-person care coordination for dual-eligibles without having to worry about whether the savings come from Medicare or Medicaid. This is good news for dual-eligible beneficiaries.

Eligibility Requirements

The CMS test model for Medicare-Medicaid ACOs will initially include six states and will last three years. States and partner ACOs that are accepted in the test model will be able start at the beginning of 2018, 2019, or 2020, depending on when they apply. The applications must include details such as the Medicaid financial methodology and shared savings/shared losses arrangements, selection of additional quality measures, and additional ACO eligibility requirements. States will also have the option to include additional Medicare-Medicaid enrollees not assigned under the Shared Savings Program and/or Medicaid beneficiaries in the target population for the Model.

The Medicare-Medicaid Model is open to all states and the District of Columbia, though CMS has stated that they will give preference to states with a low saturation of Medicare ACOs or with limited experience in Medicaid ACOs. In addition, the ACOs must be participants in Medicare’s Shared Savings Program and have a minimum number of Medicaid beneficiaries.

Care Coordination Platform

Effective whole person care coordination for dual-eligibles requires the technology to support evidence-based care and multi-agency collaboration. Care Coordination software enables healthcare organizations to achieve operational and system efficiencies, effectively manage chronic conditions, and promote collaborative team-based care to enhance patient health and safety.

Eccovia Solutions provides a powerful care coordination platform that is specifically designed for the collaborative, highly integrated Medicare-Medicaid Accountable Care Organization model. Our ClientTrack platform enables ACOs to incorporate the social determinants of health into healthcare decisions, link primary care and community services, and coordinate a seamless journey for dual-eligible beneficiaries.

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