Establishing a Home Health Agency and Accountable Care Organization (ACO) Partnership

By Gerald Buggs, MSJ

Due to the COVID-19 pandemic, the healthcare industry has experienced many changes. Specifically, for physician practices, there have been changes resulting in the expansion of telehealth services. Additionally, Home Health Agencies (HHAs) have seen some progressive changes from CMS in current polices for Remote Patient Monitoring and Telehealth services from CMS.

Additional policy changes around RPM and Telehealth services are currently being debated at the congressional level. The policy changes being considered would allow CMS to maintain some of the current COVID-19 waivers and would give CMS the authority to implement additional changes for home health and hospice providers.

At Health Recovery Solutions (HRS), our reimbursement team meets with HRS clients to advise on how to receive reimbursement from CMS, commercial carriers, or arrange a private pay program (advice varies by organizational structure and organization type).

Exploring Partnering with an ACO

More recently, the reimbursement team is advising clients on how to enter into agreements with Accountable Care Organizations (ACOs). The ACOs aim is to improve the delivery/quality of care for their Medicare Advantage and Commercial members. The ACOs goals are to provide value-based care while also improving the social determinants of health, and improving health outcomes. HHAs should explore entering into relationships with ACOs to expand their scope of services and provide new financial opportunities. To establish a partnership, the HHAs will present to the ACOs data supporting reduction of emergency department visits and re-hospitalizations via RPM management for the various disease management groups, i.e., COPD, CHF, Diabetes and Wound Care, etc.

When exploring contracting with an ACO, the HHA should consider:

  • Does the ACO require a membership fee?
  • Is the ACOs risk arrangement upside only or upside/downside?
  • What are the patient demographics of the ACO and disease management groups the ACO is at risk? How are they seeking to manage these disease groups or conditions?
  • Which payors are involved in the risk arrangement?
  • How are the ACO members incentivized?

These are only a few of the key questions that the HHA should be asking and discussing with the ACO and their senior management team before entering into an agreement. The HRS reimbursement team is available to provide support to our clients as needed throughout the process.

The ACO is going to be interested in providing coordinated care (care plan) to its members in the following areas, all of which are within the scope of the services provided by an HHA and RPM:

  • Emergent care in the ED
  • Treatment in a skilled nursing facility (SNF)
  • Chronic condition diagnosis
  • Conditions affected by the social determinants of health

The above services can be provided by an HHA and especially those HHAs that are using telehealth and RPM to augment care.

Telehealth and RPM Examples

For example, for “Care Coordination for Beneficiaries Discharged Home After a Hospital or ED Visit”, an HHA can place the patient on RPM services within 24 hours after discharge. With RPM the HHA can monitor the patient’s medication management plan, review discharge instructions and functional assessments and capture any other health issues. All post discharge services can be made readily available for review before the patient returns to the primary care physician for any follow-up visits.

When looking at patients with chronic conditions, the ACO and the HHA should look at the care management plan for the chronic disease patient. The HHA should inquire with the ACO and ask which disease management groups their members who are high-risk and high cost fall into (i.e., CHF, COPD, Diabetes, etc.) and how are they managing their care. The HHA should be aware of the patient’s gap in care related to their chronic condition. Utilization can be reduced with the proper care plan and with the implementation of RPM services that will target the diagnosed chronic conditions. Through RPM the HHA can provide hands on coaching, provide resources on the chronic condition, and improve barriers the patient my encounter when trying to access care.

Contact Our Reimbursement Team

If your HHA is interested in learning more about partnering with a ACO, please reach out to our Reimbursement Department at reimbursement@healthrecoverysolutions.com. Our reimbursement team is knowledgeable in ACO partnership development and risk contracting.

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Tags: chronic disease, reimbursement, ACOs

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