Accountable Care Organizations: The Medicare Shared Savings Program - PowerPoint PPT Presentation

Accountable Care Organizations: The Medicare Shared Savings Program CSI: "Where every client is a partner"

Accountable Care Organizations Medicare Shared Savings Program Summary Explanation of Proposed Rule Private Practice Section APTA Jerry Connolly Connolly Strategies & Initiatives connollystrategies@gmail.com 703-307-5363 CSI: "Where every client is a partner"

Themes in Health Care Reform • Prevention and wellness, Medicaid expansion, Expansion of Coverage exchanges, nondiscrimination Refining / Changing • Cuts in payment rates, refinements to payment Payment Methodologies systems, patient assessment instruments Linking Payment to • Value based purchasing, hospital readmissions Quality policy, electronic health records, registries • Provider Enrollment Program Integrity • Funding Increases for Enforcement • Expansion of Audits (RACs) • Bundling Integrated Models of • Accountable Care Organizations Care – Innovation • Medical Homes CSI: "Where every client is a partner"

Webinar Aims  Today’s purpose • Explain major provisions of the proposed rule • Answer questions (to the best of our ability) • Submit to: privatepracticesection@apta.org • Base further analysis on feedback • Prepare for 2 nd webinar  Next webinar – May 26 – 2 PM EDT • Present draft comments and “talking points” • Encourage member submissions CSI: "Where every client is a partner"

Accountable Care Organizations  Labeled the Medicare Shared Savings Program PPACA -- Section 3022  Shared savings for • hospitals and doctors changing payment models from FFS • • to model that rewards efficiency and quality • (from fragmentation to coordination) • (from volume to value)  Implementation date: 1/1/2012—this is not a pilot!  Viewed as a potential means for bending the health care cost curve  CBO scored 10-year savings of $4.9 billion CSI: "Where every client is a partner"

Case for Payment and Delivery Reform  Current Medicare FFS model results in fragmented care and breaks down care in silos  Incentivizes providers on volume of services and does not encourage clinician collaboration  Need to create a system that seamlessly coordinates care & incentivizes same  Costs of current delivery model unsustainable CSI: "Where every client is a partner"

Proposed Rulemaking for ACOs Medicare Shared Savings  Sec. 3022 of the Affordable Care Act requires CMS to establish a Medicare Shared Savings program “ by Jan. 1, 2012 that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.”  Participating entities, referred to as Accountable Care Organizations that meet quality and performance standards are eligible to receive payments for shared savings. CSI: "Where every client is a partner"

ACO -- Rulemaking Regs promulgated in four separate rulemakings: • CMS Medicare Shared Savings Program Proposed Rule: http://www.ofr.gov/(X(1)S(xrkl4mdtyvi54lavhney5kfi))/OFRUpload/OF RData/2011-07880_PI.pdf • CMS/OIG Waiver of Fraud and Abuse Certain Provisions Notice with Comment Period: http://www.ofr.gov/(X(1)S(vxlliaunmjoofe4qc13ybxl1))/OFRUpload/OFRDa ta/2011-07884_PI.pdf • FTC/DOJ Anti-trust Enforcement Policy Notice with Comment Period: http://www.ftc.gov/os/fedreg/2011/03/110331acofrn.pdf • IRS Request for Information on Tax-Exempt Status for Shared Savings Programs: http://www.irs.gov/pub/irs- drop/n-11-20.pdf CSI: "Where every client is a partner"

Accountable Care Organization - What is It?  CMS: “An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.”  Assignment to an ACO will be “invisible to the beneficiary, and will not affect their guaranteed benefits or choice of doctor. A beneficiary may continue to seek services from the physicians and other providers of their choice, whether or not the physician or provider is part of an ACO.”  Assignment methodology to be specified by CMS; based on which ACO professionals provide “the bulk of primary care services” to a particular fee-for-service Medicare beneficiary. CSI: "Where every client is a partner"

What is An ACO?  Must meet specified quality performance standards to receive a share of any savings if the actual per capita expenditures of their assigned Medicare beneficiaries are a sufficient percentage below benchmark amounts set by CMS (January 2012)  Triple Aim: 1) better care for individuals; 2) better health for populations; and 3) lower growth in expenditures  “… not just a new way to pay for care but a new model for the organization and delivery of care.” (Dr. Berwick ) CSI: "Where every client is a partner"

Common Misconceptions  An ACO is not a “provider network”  ACOs are provider-driven  ACOs do not necessarily have to involve a hospital  Not to be confused with “bundling” or the “medical home”  Participation in the ‘Shared Savings’ program not mandatory  ACOs are not paid under capitation ( not yet )  Neither ACOs nor providers or suppliers that are not ACOs will have their Medicare payments reduced [FFS] CSI: "Where every client is a partner"

Who Is An ACO Professional?  ACO professionals are defined as • a physician (ref: section 1861(r) (1)); and • a practitioner described in section1842(b)(18)(C)(i), o physician assistant, o nurse practitioner, or o clinical nurse specialist  Note: Outpatient physical therapy is referenced in section 1861(p) so NOT included in statutory definition. CSI: "Where every client is a partner"

Proposed Structure  Must have a formal and legal structure that allows the ACO to receive and distribute payments for shared savings  Formal CMS application and approval process  May be a corporation, partnership, LLC, foundation, or any other entity permitted by State law  ACO governance structure should allow for appropriate proportionate control for ACO participants, giving each ACO participant a voice in the decision-making process  Governing body must have representatives from Medicare FFS beneficiaries and each ACO provider/ participant  Allows for partnering with private entities but ACO participants must have at least 75 percent control of the ACO’s governing body CSI: "Where every client is a partner"

Proposed Structure  ACO must develop and implement evidence-based medical practice or clinical guidelines and processes for delivering care based on three part aim  ACO providers/suppliers and participants must commit to a three-year contract (CMS lays out remedial actions for removing participants for non-compliance)  5000 yearly patient threshold requirement (patients assigned to ACO by primary care utilization)  Participation purely voluntary for providers and patients  ACOs must notify patients that they are a part of an ACO and that health information will be shared among ACO providers and participants CSI: "Where every client is a partner"

Rural Exceptions  Special rules apply to certain Medicare ACOs in rural or underserved communities, such as sharing first dollar savings above the Minimum Savings Rate.  A Medicare ACO that includes a federally qualified health centers or rural health clinics receives an increase in its sharing rate, depending on the percentage of ACO-assigned beneficiaries with one or more visits to the federally qualified health centers or rural health clinics during the applicable year. CSI: "Where every client is a partner"

Participation of Medicare Beneficiaries  completely voluntary  no enrollment or assignment of beneficiaries to the Medicare ACO  allowed to receive care outside of the Medicare ACO  not required to actively choose a primary care physician “Beneficiary assignment” is used to determine whether a beneficiary • received a sufficient level of requisite primary care services from physicians associated with a specific ACO. • CMS will assign beneficiaries to a Medicare ACO’s TIN based on the primary care services they received from primary care physicians billing under that TIN, if they receive a plurality (as opposed to a majority) of their primary care services (based on allowed charges) from primary care physicians within that ACO. CSI: "Where every client is a partner"

Beneficiary Education  CMS intends to develop a communications plan to provide information on utilization of services furnished by a Medicare ACO and the possibility of being assigned to an ACO.  Medicare ACOs must notify patients that they are participating in an ACO. To improve coordination of care, CMS proposes offering access to Medicare claims data to ACOs for patients they are treating if the beneficiary grants permission. CSI: "Where every client is a partner"

Marketing the ACO  The statute is silent on marketing by ACOs;  CMS concerned about beneficiaries being misled;  All marketing materials (including revisions) must be approved by CMS prior to their use.  Failure to meet this requirement can result in corrective action or termination. CSI: "Where every client is a partner"