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Pathways to SuccessA New Start for Medicare’s ACOs Part 2
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Contents
Why the Change?
Other Key Provisions
Key Questions to Consider
Readiness
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Goal:Provide Clients an Easy
and Successful Submission Experience
“…changes are necessary because the Medicare
program had "weak incentives" for health-care
providers to slow spiraling costs…. After six years
of experience, we feel we know what works and
what doesn’t…We want to focus on delivering
value for patients and taxpayers.”
Seema Verma, Administrator of CMS
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WHAT ACTUAL RESULTS SHOW
WHY THE CHANGE?
• To quantify the move to value
• Demonstrate savings to the Medicare
program
• Promote accountability by accelerating
the move to two-sided risk
• Promote competition by encouraging
participation by low revenue ACOs
CMS GOALS
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Pathways to Success
Other Key Provisions
• Temporary changes to
ACO application cycle
• Expands voluntary
alignment opportunities
• Refines the benchmarking
methodology
• Increases monitoring of
ACO financial
performance
• Extends policies for
extreme & uncontrollable
circumstances
• Discontinues quality measure ACO-11
• Updates the repayment mechanism requirements
• Broadens the definition of primary care services for
beneficiary assignment
• Permits an expanded beneficiary incentive program
• Extends SNF 3-day waiver and telehealth coverage
• Improves program integrity & reduces gaming
opportunities
• Expands ACO termination criteria
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Temporary Changes to the ACO Application Cycle
Proposed
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Changes to the ACO Agreement PeriodProposed
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ACO Agreement Period - Proposed
Participation agreements ending on December 31, 2018, will:
✓Have the opportunity to extend agreement period for an additional 6-month performance “year”
✓Then apply for a new agreement beginning on July 1, 2019
The 6-month performance “year”
✓June 30, 2019 extensions
✓ July 1, 2019 starts
✓Would have financial and quality performance measured on a full calendar year basis and then pro-rated for determination of savings losses
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▪ Discontinuation of the double-weighted quality metric ACO-11 – Use of Certified EHR Technology
▪ Attestation & certification upon application to participate in the MSSP and annually thereafter that at least 50% of the eligible clinicians in the ACO use CEHRT to document and communicate clinical care to their patients or other health care providers
Quality Metrics Proposed
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Proposed
Beneficiary Assignment
Episodic
Source: NY DOH
▪ Currently, under Track 1 and Track 2, beneficiaries are assigned using preliminary prospective assignment with retrospective final reconciliation
▪ Under Track 3, beneficiaries are prospectively assigned
▪ The proposed rule would allow all BASIC and ENHANCED tracks the flexibility to select either method through an annual election
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Proposed
Beneficiary Assignment
Episodic
▪ Voluntary alignment opportunities started in 2018 will be expanded to any ACO professional within the ACO, not just those used in the claims-based assignment process
▪ Voluntary alignment designations will continue even though the beneficiary no longer receives primary care services from an ACO professional within the ACO
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Expansion of definition of primary care services used in beneficiary assignment to add the following new codes:
▪ 99497, 99498 (Advance Care Planning)
▪ 99160, 99161 (Health Risk Assessment Admin)
▪ 99354, 99355 (Prolonged E&M or Psychotherapy)
▪ G0442, G0443 (Alcohol Misuse Screening & Counseling)
▪ G0444 (Annual Depression Screening)
▪ GPC1X (Primary Care E&M Visit Complexity)
▪ GCG0X (Specialty Care E&M Visit Complexity)
▪ GPRO1 (Prolonged E&M or Psychotherapy)
Primary Care Services Proposed
▪ Expanded payment for certain telehealth services furnished on or after January 1, 2020 to prospectively assigned beneficiaries of ACOs under two-sided risk
▪ Receipt of telehealth services at home, to support care coordination across settings, for a period up to 90 days after the termination of assignment
▪ Would not apply to upside-only risk arrangements and two-sided risk with retrospectively assigned beneficiaries
Telehealth Services Proposed
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▪ Would make the SNF 3-day rule waiver available to the BASIC track under two-sided risk (Levels C, D, E) as well as ACOs in the ENHANCED track effective July 1, 2019
▪ Would amend the existing SNF 3-day rule waiver to allow critical access hospitals (CAHs) and other small, rural hospitals operating under a swing bed agreement to be eligible to partner with eligible ACOs as SNF affiliates for purposes of this waiver
SNF 3-Day Waiver - Proposed
© SpectraMedix, 2009-2018. The contents of this presentation are confidential and cannot be copied without prior written permission from SpectraMedix.
Effective July 1, 2019, two-sided models may operate CMS-approved incentive programs to encourage beneficiaries to obtain medically necessary primary care.
▪ Participating ACO professionals must include information on voluntary alignment in the written notifications they must provide to their assigned beneficiaries.
▪ Would require ACOs to notify patients that they are assigned in an ACO.
▪ Providers would be allowed to reward their patients with gift cards for maintaining good health.
Beneficiary Engagement
• Regional benchmarks for all agreement periods
• Mitigated regional adjustments
• Allowing for health status risk adjustment for all continuously assigned beneficiaries of ± 3% per agreement period per enrollment category
• Blended regional/national growth rates with varying national trend weights based on an ACO’s regional penetration rate
Financial Benchmarking
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Repayment Mechanisms
Lower requirements for certain BASIC track ACOs
Single payment mechanism for renewing ACOs
New requirements regarding issuing institutions
Reducing Gaming Opportunities
▪No shared savings for ACOs that are terminated within a 12-month performance year, either voluntarily or by CMS
▪No shared losses for ACOs with voluntary or involuntary terminations before July 1st of a 12-month performance year
▪Pro-rated shared losses for ACOs for both voluntary and involuntary terminations after June 30th of a 12-month performance year
▪CMS may immediately terminate ACOs with multiple years of poor financial performance (negative outside corridor) in one agreement period
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MSSP Participation
• enter/continue/discontinue?
Current Agreement
• continue/extend/discontinue?
ACO Tracks
• permitted/desired?
Key Questions to Consider
Two-Sided Risk Corridor
• population-based,
symmetrical?
Beneficiary Assignment
• prospective/retrospective?
SNF 3-Day Stay Waiver
Beneficiary Incentive Program
© SpectraMedix, 2009-2018. The contents of this presentation are confidential and cannot be copied without prior written permission from SpectraMedix.
What is Your State of Risk Readiness?
• Are you and your ACO participants educated on the Pathways risk levels?
• If so, do you have the “appetite” to take on risk?
• If yes, have you conducted your own risk assessment?
• Do you know your baseline quality compared to CMS proposals?
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Nathan Brown
Director of Marketing
609-336-7733 x308 (Office)
Thank You
Risky Business: Five Ways to Ensure You’re
Ready for the NY Medicaid Move to VBP
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