Medicare Advantage (MA), institutional special needs plans (I-SNPs), and institutional-equivalent special needs plans (IE-SNPs) are just some of the more well-known models in managed care. Although accountable care organizations¹ (ACOs) are not new to long term care (LTC), the opportunity for LTC providers to play a more significant role in ACOs is new.

Provider magazine had the opportunity to speak to Sarah Sugar and Kristen Ratcliff McGovern of Sirona Strategies and Angie Scally, Kendra Faulk-Edwards, and Zach Cattell of CarDon & Associates who share their experience working with ACOs in nursing homes, post-acute care, and assisted living. CarDon & Associates owns, operates, or manages 20 communities that offer independent living, assisted living, rehabilitation, long term care, and memory support throughout Indiana. Sirona Strategies is a Washington, DC-based government affairs firm that advises a range of different clients, including providers, payers, government contractors, health IT vendors, etc.

Provider: There has been a lot of talk and work on I-SNPs. Why is there an interest in ACOs currently, and what is the opportunity? How do ACOs complement I-SNPs?
Sirona Strategies: Participants in I-SNPs and ACOs both have experience taking on risk for patient outcomes and cost. While activity has largely centered on MA, I-SNPs are not the appropriate model of care for every LTC provider, and ACOs provide the opportunity for LTC providers to engage more meaningfully in the Medicare fee-for-service (FFS) population.
CarDon & Associates: ACOs, particularly those that serve the long-stay resident, complement I-SNPs because not every resident is going to choose an insurance-based solution for their care. ACOs are also complimentary to broader MA products.

Provider: What are some considerations that LTC and assisted living providers need to keep in mind when engaging with ACOs?
SS: ACO financial methodologies, quality reporting requirements, and attribution policies have not been designed with the LTC community in mind, which will inevitably present challenges. However, there are LTC-focused ACOs that have succeeded in the Medicare Shared Savings Program (MSSP) and in the High Needs track of the ACO REACH Model.² Finding the right partners, including other LTC providers who have experience in such a nuanced program, is critical.
C&A: It is also important to consider if there is a genuine cooperative partnership with a shared objective between the LTC provider and ACO, and if the ACO actively seeks input from the LTC or assisted living organizations, recognizing their expertise in the field. Collaboration should also extend to defining care expectations.

Provider: What are the challenges for LTC providers when partnering with an ACO?
C&A: ACO leaders often originate from the hospital and primary care sectors where ACO incentives were initially conceived and evolved. While their intentions are commendable, they may lack the hands-on experience and expertise specific to LTC management and operations. Therefore, good collaboration between LTC providers and ACOs is essential.

Also, ACO participants may utilize various hospitals and providers, making it difficult to determine their ACO affiliation. Without this knowledge, LTC providers cannot leverage added resources, care coordinators, or the 3-day waiver benefit, hindering collaboration and care. A robust identification system can help manage unnecessary spending and enhance care quality. Ideally, checking a resident’s Medicare benefits should reveal their ACO affiliation from day one.

Provider: What are the benefits?  
SS: Given that I-SNPs typically have limited penetration, an ACO provides an opportunity for LTC providers to benefit from the residents who chose not to enroll in an I-SNP. ACOs also encourage coordination between community-based and LTC providers, who often operate in a silo from one another, and offer more reliable and resilient payment methodologies than traditional FFS.
C&A: Benefits in all settings encompass improved collaboration and the ability to align residents with appropriate resources and care management. This allows for the teams to collaboratively work together to avoid unnecessary treatment ultimately leading to good stewardship of Medicare money while not sacrificing patient care options and treatments.

Provider: What is the future of ACOs in LTC in the next five years?
SS: Long term and post-acute care have played an essential role in the success of most value-based care models, with some of the most significant improvements in care and cost savings generated by intentional and targeted post-acute care partnerships. ACOs will continue to prioritize effective engagement and meaningful partnership with the LTC community to realize increased efficiencies, improved outcomes, and reduced health care costs.
As CMS strives to grow the MSSP and achieve its goal of having all Medicare Part A and B beneficiaries in accountable care relationships by 2030, there will be an increasing attention to ensuring the LTC community has a pathway for meaningful participation in ACOs.
C&A: We think the future of ACOs in LTC is bright, and our experience with LTC-focused ACOs is positive due to our ACO partners’ willingness to dig in with us to understand our LTC perspective and then act on it.

Natalie Visnick is senior manager of public affairs for the American Health Care Association/National Center for Assisted Living.

References
1. https://educate.ahcancal.org/products/accountable-care-organizations-2
2. https://www.cms.gov/priorities/innovation/innovation-models/aco-reach