The CMS Pioneer ACO initiative encourages primary care doctors, specialists, hospitals and other health care providers to better coordinate care for patients on Medicare. MACIPA’s Care Managers and Care Coordinators work closely with physicians to provide additional individualized support for patients who are hospitalized, in a skilled nursing or rehabilitation facility, and for the chronically ill and frailest patients living in their homes. Care coordinators are Registered Nurses who work with physicians to facilitate and coordinate the patient’s discharge from the hospital. They ensure the patient is ready to be discharged, has a follow-up appointment with their physician shortly after discharge and that the patient understands instructions about medicines, follow-up care, or whether home care services or equipment are needed.
The payment models being tested in the first two years of the Pioneer ACO Model are a shared savings payment policy with generally higher levels of shared savings and risk for Pioneer ACOs than levels currently proposed in the Medicare Shared Savings Program. In year three of the program, participating ACOs that have shown a specified level of savings over the first two years will be eligible to move a substantial portion of their payments to a population-based model. These models of payments will also be flexible to accommodate the specific organizational and market conditions in which Pioneer ACOs work.
