About (PCM) Prime Care Managers ACO
In January 2017, PCM was designated as an Accountable Care Organization. As an independent primary care ACO, our primary care providers were assigned 7,500 Medicare Beneficiaries in our initial year. These Beneficiaries are scattered across northeast Texas and southern Arkansas region. Approximately 50 primary care providers represented by 13 unique taxable entities participated in our initial filing.
Since then, we have grown to include additional independent entities adding another 60 primary care providers and some specialists. Our total independent physician participation now exceeds 150, with 15 unique entities. Our expected assigned Medicare Beneficiaries is expected to exceed 15,000 in 2018. As an ACO, our primary care providers have delegated the responsibility by CMS to manage the total cost of care for our assigned Beneficiaries regardless of where and by whom it is provided. We believe an independent and unaffiliated physician organization provides our beneficiaries the greatest hope for accountability and value.
CLAIMS & RISK DATA
As an Accountable Care Organization, we receive monthly updates of detailed claims information from the Centers for Medicare and Medicaid Services (CMS) for assigned beneficiaries. The cost and utilization data is specific by data of service for each claim encounter submitted to CMS. The claim data is comprehensive to all information provided on a submitted claim, including provider, facility, procedure, diagnosis, and supplies for all Part A, B, and D claims.
The purpose of receiving claims information is to give an ACO insight into area providers' cost and utilization practices. To some degree, we are able to compare specific providers and measure their performance to local, regional and national benchmarks. We are also supplied a means to measure the relative risk of a specific beneficiary. In addition to CMS supplying us with a Hierarchical Condition Category risk score (HCC) for each beneficiary, we are able to predict risk based on diagnostic codes and historical use patterns. Our ability to predict risk allows us to adjust care plans and interventional activity to prevent and better manage future treatment options.
BUILDING A NETWORK
We realize that claims data relative to risk is not the only source for evaluating providers' quality, outcomes, and cost. There are many other factors that drive the ability to align providers into high-value networks of healthcare delivery. Our ACO will evaluate self-reported data from area providers to form an accountable high-value network. The self-reported data includes ownership structure, physician alignment, patient engagement, coverage area, service levels, staffing, clinical pathways, specific clinical performance, risk management, and the ability to integrate into a value-oriented network clinically.
Our goal as an ACO is to work with multiple provider options in the marketplace. It is not our intent to exclude providers who can meet our objectives. Rather, it is our desire to build accountable long-term relationships with providers who continually demonstrate integrated capabilities that add value to Beneficiaries. Our goal is to build sustainable partnerships and grow our capabilities over time. Attached is a Request for Information (RFI) detailing questions that will provide us with additional insights into your organization. We appreciate your complete response. Any supportive documents are welcome.
Please forward information to:
Prime Care Managers, LLC ACO • 4002 Technology Center • Longview, TX 75605
We appreciate your participation in this important endeavor in our community. If you have any questions, please contact:
Tom Stamper / ACO Network Development
(903) 247-0484 x238 • firstname.lastname@example.org
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