Can Medicaid be a Model for ACO Innovation?
"The philosophy behind them can be described as a tug of war," says Enders. "Providers feel like they should do the medical management," he says.
Where you see innovation in business strategies, structure, and payment methodologies surrounding accountable care organizations, Enders is usually right in the thick of it, especially as it concerns governance and contractual structure.
His firm has been engaged by many in setting up the structures behind these entities, which often can take the form of joint ventures or contractual agreements. But the big difference between what he and his team are setting up and Medicare Shared Savings, for example, is that they are often full risk.
This is a contrast to Medicare shared savings, and more akin to the CMS Pioneer ACO program, which several organizations recently dropped, presumably because they couldn't make the numbers work. But further examination of the Pioneer "dropouts" will reveal the fact that providers have a tough time stratifying their patients, which is the hinge on which shared risk pivots.
"There's certainly a perspective that payers have spent years developing the claims-based system, and that gives them the ability to stratify patients," he says. "Patient stratification requires algorithms that are able to draw on a large data set and provide predictive modeling. Payers have that and providers don't. So providers who are rapidly transforming themselves into systems of care realize they don't have the ability to manage risk or manage care from stratification of patients."
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