Responding to the Proposed ACO Rule: Positions, Insight and Guidance - PowerPoint PPT Presentation

Responding to the Proposed ACO Rule: Positions, Insight and Guidance for PPS Members CSI: "Where every client is a partner"

Accountable Care Organizations Medicare Shared Savings Program Draft Comments on 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"

Accountable Care Organizations  Labeled the Medicare Shared Savings Program  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"

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"

Purpose of Today’s Webinar  Review DRAFT comments to the rule  Provide specific suggestions for comment  Provide education and generate discussion  Encourage PPS members to comment CSI: "Where every client is a partner"

Questions from 1 st Webinar  Can a PTPP join more than one ACO?  Is there a limit to the amount of ACOs a PT practice can partner with? (e.g. 1 PT in 5 ACOs)  Is there a limit to the amount of PTs an ACO can partner with? (e.g. 5 PT’s in 1 ACO)  What protections are there for the independent practitioners to be a part of the solution?  Will an independent provider be able to share in cost savings if they are integral in making the ACO successful? CSI: "Where every client is a partner"

Questions from 1 st Webinar  How will CMS monitor antitrust activities to insure that subscribers have an opportunity to go to a non ACO participant?  If a subscriber to an ACO receives care outside their “approved provider” network, will that subscriber be scrutinized by the ACO for leaving their delivery system? How will this be prevented?  Will the ACO be able to positively steer a subscriber to one of their providers and away from a patient choice? Will they be able to pressure subscribers? CSI: "Where every client is a partner"

Questions from 1 st Webinar  With respect to shared savings, what exactly they are comparing in regards to the cost, i.e., are they looking at this based on cost per diagnosis code vs overall cost per beneficiary in a given calendar year?  Is this factored per patient or by an overall average of patients with that diagnosis?  Are they looking at average cost per diagnosis code and then factoring in additional diagnosis codes, co-morbidities, etc.? CSI: "Where every client is a partner"

Questions from 1 st Webinar  Since a Medicare subscriber can go to any provider within the ACO system or outside the ACO system, what benefit is there to being a part of the ACO? 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"

Background  Providers of services and suppliers were listed in that Statute as eligible to participate:  ACO professionals in group practice arrangements.  Networks of individual practices of ACO professionals.  Partnerships or joint venture arrangements between hospitals and ACO professionals.  Hospitals employing ACO professionals.  Such other groups of providers of services and suppliers as the Secretary determines appropriate. CSI: "Where every client is a partner"

Background/Comment  PPS/APTA is pleased that the proposed rule recognizes the ability of PPPTs to participate in ACOs through the establishment of the category of “ACO Participant.” CSI: "Where every client is a partner"

Definition  An ACO is defined as a group of health care providers accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to the organization. It must meet specified quality performance standards to receive a share of any savings individual practices of ACO professionals.  Partnerships or joint venture arrangements between hospitals and ACO professionals.  Hospitals employing ACO professionals.  Such other groups of providers of services and suppliers as the Secretary determines appropriate. CSI: "Where every client is a partner"

Definition/Comment  PPS/APTA is generally supportive of any program that rewards high-quality, cost- effective care. However, a number of concerns that could result in a negative impact on independent providers who operate as small businesses and the patients they serve. CSI: "Where every client is a partner"

Structure  Application and approval process.  ACO may be a corp, partnership, LLC, foundation, etc.  Appropriate proportionate control by ACO participants.  Medicare patient and ACO providers on board  ACO participants must have at least 75% control  Allows for partnering with private entities  Must do evidence-based medicine or clinical guidelines  Serve Triple Aim [better care, better health, lower cost]  Participation voluntary for providers and patients.  ACOs must notify patients that • they are a part of an ACO and • health information will be shared among ACO CSI: "Where every client is a partner"

Structure / Comment  Financial/clinical integration implications? • Participating in >1 ACO  What assurance inducement not permitted  Private entity contracting loophole • Unqualified workers not allowed in patient care CSI: "Where every client is a partner"

Leadership & Management  Infrastructure  Senior-level medical director  Commitment to clinical integration  Health information technology  Feedback to providers/participants  QA/CI programs described  Adherence to EBM/clinical guidelines CSI: "Where every client is a partner"

L & M Comment  HIT resources lacking – disadvantage PTs  De facto disqualification?  Inclusion safeguards for nonphysicians CSI: "Where every client is a partner"

Governing Body  75% participant control  Partner with community stakeholders  Partner with Medicare FFS beneficiaries CSI: "Where every client is a partner"

Governing Body/ Comment  75% participant control  Partner with community stakeholders  Who are stakeholders?  Should include PPPTs CSI: "Where every client is a partner"

Sufficient Number of PCPs  Serve 5000 Medicare FFS patients  PCPs must have EHR by Yr 2  Report list of providers/ participants annually CSI: "Where every client is a partner"

Sufficient Number of PCPs/Comment  Must have sufficient number, type, and location of providers for necessary care  Beneficiary assignment retroactive • Problematic • Can’t project savings • Implications for business plan • Operating capital CSI: "Where every client is a partner"

Beneficiary Info and Notice  CMS communications plan • Shared savings • Utilization of service • Possibility of beneficiary assignment  ACO communication • Participating in Medicare Shared Savings Program • Written notice to beneficiaries • Sharing of health information – request for authorization CSI: "Where every client is a partner"