Introduction to ACO

Siqin Ye, MD, MS

Associate CMO, ColumbiaDoctors

How Medicare ACO Works

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ACO Status New York Quality Care

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• CUMC, Cornell and NYPH working together − Equal ownership – 1/3 each − Equal capital contributions

• All MDs at CUMC, Cornell, and NYPH are considered as

one group.

• 30,000+ patients in ACO

• Reduction of cost to achieve shared savings

• Medicare reimbursements for ALL determined by performance of this ACO

Care Management Team

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• 5 care managers in each entity

• Identification of high care utilizers

• Follow patients with primary care provider −Avoid ER visits −Avoid admissions

• ESRD program −HD 24/7 −Dialysis center

ACO Status New York Quality Care

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• CUMC, Cornell and NYPH working together − Equal ownership – 1/3 each − Equal capital contributions

• All MDs at CUMC, Cornell, and NYPH are considered as

one group.

• 30,000 patients in ACO

• Reduction of cost to achieve shared savings

• Medicare reimbursements for ALL determined by performance of this ACO

How is payment schedule determined

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• Current −PQRS (Physician Quality Reporting System) −VBM (Value Based Modifier) −Meaningful Use

• Set 2 years ahead −2017 – already set based on 2015

performance

MACRA (Medicare Access and CHIP Reauthorization Act of 2015)

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• Goes into effect for payment schedule for 2019

• 2 Choices − MIPS (Merit-based Incentive Payment Syatem)

o 2019 – Fee schedule (set on 2017 performance) oMerging of PQRS, VBM, Meaningful use

− APM (Alternate Payment Method) oCapitation

Migration to MIPS

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MIPS (Merit Based Incentive Payment System)

Factors Deciding Payment Schedule

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• Measures −Quality Metrics −HCC Disease severity coding

• 2019 (decided by 2017 performance) −NO neutral zone −Up to 4% penalty −Up to 12% bonus −2020 and beyond o Increasing penalty OR bonus

ACO Quality Metrics

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• 34 quality measures (18 are GPRO):

− 10 Care Coordination/Safety − 8 Patient Caregiver Experience − 8 Preventive Health − 8 Clinical Care for At Risk Populations

• Tracked at FPO for CU, then sent to NewYork Quality

Care for merging with Cornell and NYPH data

Provider and Group Level Scorecards

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GPRO Scoring Report Card

GPRO Measure # Description 2015

2016 Year-to-

Date 2016

Projected 2016 Goal Assessment

Care-3 Documentation of current medications in the medical record 25% 4% 50% 75%

Care-2 Falls: screening for future fall risk 20% 10% 50% 75% Prev-7 Influenza Immunization 40% 10% 50% 100% Prev-8 Pneumonia vaccination 30% 11% 50% 100% Prev-9 Body mass index screening and follow-up 45% 45% 75% 80%

Prev-10 Tobacco use: Screening and cessation intervention 50% 40% 80% 80%

Prev-12 Screening for clinical depression and follow-up plan 50% 30% 70% 75%

Prev-6 Colorectal Cancer Screening 75% 43% 75% 85% Prev-5 Mammography Screening 30% 11% 50% 75%

Prev-11 Screening for high blood pressure and follow-up documented 75% 50% 75% 85%

DM-7 Eye Exam 80% 50% 90% 90%

DM-2 Percent of beneficiaries with diabetes in poor control (HbA1c >9)% 80% 60% 100% 100%

HTN-2 Percent of beneficiaries with hypertension whose BP

HCC (Hierarchical Conditions Category)

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• Disease severity is determined by CODING

− Determines benchmark cost for taking care

of patients − Determines reimbursement in some cases

13 13 © Oliver Wyman | CHI-NYX100-11

Correct Coding of Diabetes Mellitus Type II With Chronic Complications

Documented Diagnosis ICD-10 Code HCC RAF

DM with no complication stated E11.9 19 .118

DM with kidney complication(s) E11.2* 18 .368

DM with ophthalmic complication(s) E11.3.** 18 .368

DM with neurological complication(s) E11.4* 18

.368

DM with peripheral circulatory complication(s)

E11.5* 18

.368

DM with other specified complication(s)

E11.6** 18 .368

Examples of diagnoses that are NOT Risk Adjustable (RAF = 0): • Pre-diabetes • Borderline diabetes • Abnormal glucose • Elevated glucose

Representative typical case 75 year old diabetic female with CKD and symptoms of UTI Patient is tired, less energy and poor appetite. Patient has CKD stage 4 due to diabetes, mild malnutrition, is frail and has lost 30 lbs. in the past 6 months. Urinalysis performed which shows evidence of a UTI. Patient has been complaining of urinary discomfort, weakness, and has had dry, itchy skin with tingling for the past 6 months PMH: Diabetes mellitus, chronic kidney disease stage 4, right BKA, stable Assessment: DMII, CKD stage IV, UTI Plan: Glucophase 500 mg b.i.d. for DM. Cipro for UTI. Ensure supplements for malnutrition. RTC in 3 months

Representative typical case Scenario 1 – Represents what is typically coded and reported by many providers

Scenario 2 – Represents what could be coded and reported with correct documentation and coding initiatives

15 © Oliver Wyman | CHI-NYX100-11

Condition ICD 10 code RAF Demographic score Total RAF

Diabetic CKD Stage 4 E11.22 .368

2.521 UTI N39.0 0

ILLUSTRATIVE

Demographic

Condition ICD 10 code RAF score Total RAF Diabetes Mellitus E11.9 .118

CKD stage 4 N18.4 .224 .437 .779

UTI N39.0 0

CKD Stage 4 N18.4 .224 .437

Protein calorie malnutrition

E44.1 .713

R BKA status Z89.511 .779

Distribution of Patients

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• 30,000 overall patients in ACO • 15,000 at CUMC −Highly concentrated −11,000 patients with 140 MDs

Achieving Goals

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• Education programs for MDs with many attributed patients −Quality Metrics −HCC

• Direct Incentive program to MDs with high attribution

• Building new care models −Specialists can play valuable role

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Introduction to ACOHow Medicare ACO WorksACO Status�New York Quality CareCare Management TeamACO Status�New York Quality CareHow is payment schedule determinedMACRA�(Medicare Access and CHIP Reauthorization Act of 2015)�Migration to MIPSFactors Deciding Payment ScheduleACO Quality MetricsProvider and Group Level ScorecardsHCC �(Hierarchical Conditions Category)Correct Coding of Diabetes Mellitus Type II With Chronic Complications Representative typical caseRepresentative typical caseDistribution of PatientsAchieving Goals�Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22