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Call them what you will—accountable care organizations, clinically integrated networks, community care organizations—collaborative efforts between independent providers are cropping up to address the challenges created by new payment and delivery models. Already faced with disparities in healthcare not found in urban areas, rural providers must develop new affiliation strategies to overcome these obstacles. PYA Principal Martie Ross, in partnership with the National Rural Health Association, conducted a Rural Accountable Care Organizations webinar, "Medicare Shared Savings Program--Foundation for a Clinically Integrated Network."
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Page 0May 2014
Prepared for National Rural Health Association
Medicare Shared Savings Program
Foundation for aRural Clinically Integrated Network
May 2014©2014 Pershing Yoakley & Associates, PC.
No portion of this PowerPoint presentation may be used for any purpose other than anindividual’s own educational purposes without the express written permission of PYA.
Page 1May 2014
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• Per se illegal for independent market participants tonegotiate jointly on price-related terms
• Three options
– Messenger model
– Economic integration
– Clinical integration
Antitrust Basics
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• Provider organization cannot exercise market power inanti-competitive manner
– Market power = immune from competition
– Presume market power from market share
– Overcome presumption by demonstrating pro-competitiveeffects
Antitrust Basics
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• FTC guidance
– Statements of Health Care Antitrust Enforcement Policy
– Consent decrees and advisory opinions
– MSSP safe harbors
• Bottom line: Does the organization maintain high degreeof interdependence and cooperation to control costs andensure quality?
Clinical Integration
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Clinical Integration
• Providers accountable to each other and tocommunity to deliver high-quality care inefficient manner
– Collectively define and enforce standards of care
– Coordinate patient care
– Identify and pursue efficiencies
• Crucial strategy for value-based purchasing,population health management
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Clinically Integrated Network
• Lean infrastructure to support provideraccountability
• Vehicle for independent providers to jointlynegotiate with payers
– Access to patients
– Aggregate risk
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• Brings together providers from multiple communities
• Unique focus on continuum of care and economies ofscale
• Aggregate risk
• a/k/a Community Care Organizations
Rural Clinically Integrated Network
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Participation Agreement
• Individual providers join a CIN by signing aparticipation agreement
• Terms of agreement established by CINgoverning body
– Parties’ respective rights and responsibilities
– Demonstrates CIN legitimacy to payers
• Breach = remedial action, termination
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Polling Question #1
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CIN Functions
• Core functions
– Promote evidence-based medicine
– Facilitate care coordination
– Negotiate and manage payer contracts
• Additional support services
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Promote Evidence-Based Medicine
• EBM = integrating individual clinical expertise with thebest available external clinical evidence from systematicresearch
• Clinical protocols
– Identify (prioritize)
– Implement (education, technology solutions)
– Monitor (reporting on quality measures)
– Remediation, punitive measures
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Facilitate Care Coordination
• Identify high-risk, high-cost patients
– Disease registries
– Data analytics
• Aggressive interventions
– Patient navigator
– Remote monitoring
– Transitional care management
– Health information exchange
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Manage Payer Contracting
• Standard fee schedule
• Narrow networks and tiered benefits plans
• Pay for performance
• Shared savings programs
• Bundled payments
• Centers of Excellence
• Global budgets
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Shared Savings ProgramsKey Contract Terms
• Identify parties to contract
• Define population/attribution
• Calculate total-cost-of-care benchmark
• List quality metrics
• Set out minimum performance standards
• Specify savings percentage
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Shared Savings ProgramPerformance
• Attribute patients and set benchmark
• Providers continue to bill fee-for-service
• Track performance on quality metrics
• Calculate payer’s actual total cost of care for specified period
• Actual TCC – benchmark = savings
• Payer pays CIN percentage of savings
• CIN allocates savings among participants, others
• Adjust benchmark, start over
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One-Sided vs. Two-Sided
• One-sided – If actual costs exceed benchmark,CIN not liable for difference
• Two-sided – If actual costs exceed benchmark,CIN liable for difference
– Eligible for greater share of savings
• Window of opportunity on one-sided model isclosing rapidly
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• 340 participating ACOs; very few rural providers
• Three-year contracts
– Each year = performance year
– One-sided available first contract term only
• Next start date is January 1, 2015
– NOI due May 30
– Application due July 31
Medicare Shared Savings Program
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• Shared savings
• PQRS reporting
• Private payer credibility
• Waivers
MSSP Advantages
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• Lift restrictions of Stark law, Anti-Kickback Statute,gainsharing, and beneficiary inducement CMPs
– State laws and federal antitrust and tax laws still apply
• Two primary waivers: ACO pre-participation and ACOparticipation
• Three secondary waivers
– Patient incentives
– Shared savings distributions
– Stark law compliance
MSSP Waivers
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Pre-Participation Waiver• Governing body makes bona fide determination that
arrangement reasonably related to MSSP purposes
– Includes “promoting accountability,” “managing andcoordinating care,” and “encouraging investment ininfrastructure and redesigned care processes”
• Complete and contemporaneous documentationwith public disclosure as required by HHS
• Effective through start date of participationagreement or date of application denial letter (with6 months to unwind)
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Participation Waiver• Requirements
– Current MSSP participant in good standing
– Governing body makes and duly authorizes a bona fidedetermination that arrangement reasonably related to MSSPpurposes
– Complete and contemporaneous documentation with publicdisclosure as required by HHS
– Cannot include incentives to limit medically necessary itemsand services
• Timeframe
– From effective date through 6 months following expiration ortermination of participation agreement (and renewals)
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MSSP ACO Formation
• Legal entity
• Governing body
– 75 percent ACO participants
– 1 independent Medicare beneficiary
– Fiduciary duty (not responsible for governing activities ofindividuals or entities outside the ACO)
• Management
– Board-appointed manager
– CMO, QA-QI professional, compliance officer
– Audit and record retention requirements
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• Sufficient number of PCPs to achieve 5,000 attributedbeneficiaries
• Any other Medicare providers in good standing
• “Other entities”
MSSP ACO Participants
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• Identified by TIN
• Includes all providers/suppliers that bill through thatprovider number (reassignment)
• If TIN bills for any primary care service, TIN is exclusive tothat ACO
MSSP ACO Participant
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Required Agreements
ACO
TIN
NPI
Accountable Care Organization (CIN)
Physician Practice
Each Physician WhoReassigns to Physician Practice
ParticipationAgreement
ParticipationAgreement
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• Executed prior to submission of application
• Explicit agreement to participate in MSSP and adhere to42 CFR Part 425
• Participants’ rights and obligations
• Termination based on non-compliance
• No referral requirements
Participation Agreement
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• 4-physician group practice; each reassigns billing rights to group
• Practice can participate in MSSP as part of ACO only if all 4physicians agree
• If practice bills for any primary care service, practice is exclusiveto that ACO
• Physician can participate in another ACO only if billed throughanother TIN
– Group practice exception
• “Other entity” option
– Governing body participation
Example
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• Mission, vision, values
• Sample participation agreement
• List of ACO participants
– Notify CMS within 30 days of any change
– Updated list at the beginning of each performance year
• Conflicts of interest policy and signed disclosurestatements
• Job descriptions for required staff
• Organizational chart (governance and management)
MSSP Application - Details
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• Describe how the ACO will:
– Establish and maintain quality assurance andimprovement program
– Promote evidence-based medicine, patientengagement, care coordination, patient-centeredness
– Compile and report participants’ quality measurescores
– Distribute shared savings and assess shared losses
MSSP Application - Narrative
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MSSP Attribution
Primary Care Services
• E&M Services
– 99201-15; 99304-99318;99324-99340; 99341-99350
• Wellness Visits
– G0402, G0438, G0439
• RHC/FQHC Services
– 0521, 0522, 0524, 0525
Primary Care Physicians
• Family Practice
• General Practice
• Internal Medicine
• Geriatric Medicine
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MSSP Attribution – Step 1
• Identify beneficiaries who received a PC service fromACO’s PCPs in last 12 months
• Attribute beneficiary to the ACO only if:
Total allowed chargesfor PC services billed byACO’s PCPs in last 12months
Total allowed chargesfor PC services billed byPCPs in any other ACOor non-ACO TIN in last12 months
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Step 1 Example
Beneficiary Organization PCPs Specialists +Mid-levels
A1 ACO $400 $600
A1 Other MSSPACO
$350 $1000
A1 Group Practice $375 $800
Allowed Charges for PC Services
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MSSP Attribution – Step 2
• Identify non-Step 1 beneficiaries who received a PC service froman ACO specialist physician within last 12 months
• Attribute beneficiary to ACO only if:
Total allowed charges forPC services billed by allACO physicians and mid-levels in last 12 months
Total allowed charges forPC services billed by PCPsin any other ACO or non-ACO TIN in last 12 months
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Step 2 Example
Beneficiary Organization PCP All physicians+ mid-levels
A2 ACO $0 $400
A2 Other MSSP ACO $0 $350
A2 Group Practice $0 $375
.
Allowed Charges for PC Services
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• FQHCs
• RHCs
• CAHs billing Method II billing
MSSP Attribution – Rural Considerations
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Polling Question No. 2
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Beneficiary Eligibility
During the last 12 months, beneficiary has:
• At least one month of Part A and Part B enrollment
• No months of:
– Part A enrollment only
– Part B enrollment only
– Medicare Advantage enrollment
– Group health plan enrollment
– Non-US residence
• Received at least one PC service billed by ACO physician
• Not been included in other shared savings initiatives
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• Many applicants denied participation due to insufficientattribution
• Identifying attributed beneficiaries
– Quarterly preliminary assignment lists
– Final assignment report at end of the year
Attribution Experience
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Setting the Benchmarks
• Identify all beneficiaries who would have beenattributed to ACO in each of 3 prior years
• Divide into four categories: ESRD; disabled; elderlydual eligible; elderly non-dual eligible
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• Calculate per capita 3-year average total cost of care foreach category
– Exclude IME and DSH payments
– Cap at 99th percentile (avoid catastrophic claims)
– Trend using national Medicare growth factors
– Risk adjust to reflect most recently benchmark year
• Update annually by projected growth in Medicarespending; other updates based to changes to ACOparticipant list
Setting the Benchmarks, Cont’d
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CMS Data Requests
• At ACO’s request, CMS will provide aggregate claims datafor preliminarily assigned beneficiaries
• Data enables ACO to identify savings opportunities
• No data use agreement or beneficiary notificationrequired because no protected health information
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CMS Data Requests• ACO may receive certain beneficiary identifiable claims
data, but only if:
– ACO has signed HIPAA-compliant data use agreement
– ACO notifies beneficiaries of opportunity to opt out of suchdata sharing
– Beneficiary has not exercised opt-out rights
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CMS Data Requests
CMS also shares aggregate beneficiary reports at thebeginning of the start of the agreement period, whichinclude:
1. Aggregated metrics on the assigned beneficiarypopulation
2. Utilization and expenditure data based on historicalbeneficiaries used to calculate the benchmark
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Allocation of Savings
• May include non-ACO participants
– Other entities
– Management company/investors
• Provider buy-in
• Easy to understand, implement
• Recognize all patients not created equal
• Incentives for evidence-based medicine, carecoordination
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Minimum Thresholds
• Quality measures
• “Good citizenship” requirements (examples)
– Maintenance of Board certification
– Specialty-specific CMEs
– Use of Category II codes
– Use of registry
– Engagement with med management staff
– Committee participation/attendance
– Generic Rx utilization
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PCPs
• Incentives to effectively manage patient care
• Example: Allocation based on individual PCP’spatient population’s actual total cost of care vs.risk-adjusted target
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Specialists
• Incentives to provide high-quality care in cost-effective manner
• Examples
– Value-based purchasing modifier (QRUR/MIPS)
– Risk-adjusted patient volumes
– Cost per episode of care
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Specialists
• Financial rewards for services to CIN
– Defining appropriate use criteria for referral tospecialists
– Specifying appropriate indications for diagnostic andtherapeutic interventions
– Establishing performance measures related tospecialty care
– Developing innovative solutions to enhancecommunication between PCPs and specialists
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• Offset investment
• Offset declining revenues
Hospital
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Per Capita Medicare Spending
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Polling Question #3
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Martie RossPershing Yoakley & Associates, PC
9900 W. 109th Street, Suite 130Overland Park, KS 66210
