ACO Emerging Trends -Lessons Learned on ACO Start-Up

Transcription

1 ACO Emerging Trends -Lessons Learned on ACO Start-Up This roundtable discussion is brought to you by the ACO Task Force September 14, 2012, Noon to 1:15 pm Eastern Presenters: Christi J. Braun, Esquire Member, Mintz Levin, Washington, DC, Robert A. Gerberry, Esquire Associate General Counsel, Summa Health System, Akron, OH, Rick L. Hindmand, Esquire Member, McDonald Hopkins LLC, Chicago, IL, Moderator: David A. DeSimone, Esquire VP & General Counsel, AtlantiCare, Egg Harbor Township, NJ,

2 OVERVIEW Medicare Shared Savings Application, including recent changes Operational Issues Physician Exclusivity Operating in Medicare and Commercial Payor worlds Provider Agreements (time permitting) Questions

3 State of ACOs PGP Demonstration Sites 10 participants Pioneer ACOS 32 participants Medicare Shared Savings Program (MSSP) April participants July participants MSSP January 1, ACOs filed Notice of Intent Application Deadline September 6, 2012

4 ACO Glossary Population Health Management Triple Aim Evidenced Based Medicine Patient Centered Medical Home Quality Metrics Shared Savings/Shared Losses

5 MSSP Application An Evolving Process (Christi) Key Changes to the application for January 1 start date, as compared to the April 1/July 1 application: Implication of providing certain yes or no answers was made clear by restating that these answers indicate that the ACO is certifying compliance with specific prerequisites Required submission of a narrative of ACO s history, mission, and organization, including affiliations Must identify the ACO legal entity s tax status In table identifying members of the governing body, must indicate the voting power of each director/managing member New attestation regarding, and required identification of, merged/acquired participant TINs Submit signature pages for ACO participant agreements ACO Participation Agreement template (see next slide)

6 ACO Participation Agreement Template Citations to: Required compliance with Medicare Shared Savings Program requirements and conditions (42 CFR Part 425), including ACO s agreement with CMS The ACO participants and ACO providers /suppliers rights and obligations in and representation by the ACO How the opportunity to get shared savings or other financial arrangements will encourage adherence to the quality assurance and improvement program and evidence-based clinical guidelines Remedial measures that will apply in the event of noncompliance with the requirements of their agreements with the ACO

7 Inconsistent Guidance from CMS IPAs/PHOs as owners of an ACO (a) states, The following ACO participants or combinations of ACO participants are eligible to form an ACO (2) Networks of individual practices of ACO professionals (3) Partnerships or joint venture arrangements between hospitals and ACO professionals July 25 th FAQ non-medicare-enrolled entities are not eligible to form a Medicare Shared Savings Program ACO. However, it was our intent in the final rule to provide flexibility for Medicareenrolled providers and suppliers to join with others

8 Clarification of Intent? Participation Agreements (c) mentions participation agreements but doesn t say ACO must sign directly with each practice or physician September 11 th guidance : The agreements must show a direct agreement between the ACO and ACO participant TIN. The agreement may not have a 3rd party intermediary. Emphasis in the original

9 Operational Issues Identifying a Medicare beneficiary representative served by the ACO No personal or familial conflict of interest with the ACO CMS is providing 1 year of historical data and no commitment to provide the other two years used in the calculation of the benchmark Notification of beneficiaries of their right to opt out CMS provides name, DOB, HICN, and sex of attributed beneficiaries. To contact prospective assigned beneficiaries in writing regarding the data opt-out right, ACO needs an address CMS says ACO participants have the addresses, but won t identify ACO Participant responsible for attribution

10 Physician Exclusivity (Rick) 42 CFR (b): Each ACO participant TIN upon which beneficiary assignment is dependent must be exclusive to one ACO ACO participant TINs upon which beneficiary assignment is not dependent are not required to be exclusive to one ACO

11 Step-Wise Assignment Primary Care Physician 42 CFR Step 1- A beneficiary who receives at least one primary care service from a primary care physician during the measurement period will be assigned to the ACO if: Allowed charges for primary care services furnished to the beneficiary by all primary care physicians of the ACO > Allowed charges for primary care services of primary care physicians who are either (A) in another ACO or (B) identified by a Medicareenrolled TIN and not affiliated with any other ACO

12 Step-Wise Assignment - Specialists Step 2 - A beneficiary who receives at least one primary care service from an ACO physician but no primary care services from any primary care physician will be assigned to an ACO if: Allowed charges for primary care services furnished to the beneficiary by all ACO professionals (e.g., physicians, PAs, NPs, CNSs) > Allowed charges for primary care services furnished to the beneficiary by all physicians, PAs, NPs and CNSs who are either (A) in another ACO or (B) identified by a Medicareenrolled TIN and not affiliated with any other ACO

13 Primary Care Services (definition) 42 CFR primary care services services identified by the following HCPCS codes: (office or outpatient E&M visits) (E&M services in a nursing or similar facility) (E&M home visits) G0402 (Welcome to Medicare visit) G0438 or G0439 (annual wellness visits) Revenue center codes 0521, 0522, 0524 or 0525 for FQHC or RHC services

14 Primary Care Physician (definition) 42 CFR primary care physician a physician who has a primary specialty designation of Internal medicine General practice Family practice Geriatric medicine For services furnished in an FQHC or RHC, a physician included in an attestation by the ACO

15 Exclusivity Planning Challenges Difficulty of ensuring specialist nonexclusivity Broad use of primary care codes Plurality (not majority) of allowed charges No threshold a single visit could trigger exclusivity Assignment can be dependent on other physicians Collective determinations at the ACO and TIN levels General expectation of specialist nonexclusivity Potential clash between ACOs Overlap -physician/group participation on multiple ACOs Potential impact on 5,000 beneficiary threshold

16 Exclusivity Planning Challenges (cont d) Potential turf battles within group practices Separate TIN: Stark Law : Group practice definition - 42 CFR In-office ancillary services exception - 42 CFR (b) Anti-markup rule - 42 CFR Supervision State law Logistics Employees Obligations to group practice and third parties Antitrust

17 Experience in Medicare & Commercial ACO Programs (Rob) Potentially utilize experience in Commercial ACO prior to participating in Medicare Program Commercial payers testing different demonstration projects Partner with own Health Plan or System s employees to test model Synergy of efforts across entire patient population-not just halo effect Develop Infrastructure to handle different populations and program requirements

18 Differences between Medicare & Commercial ACOs Key Differences: Financial Shared Savings Amount 50/50 Split-MSSP Negotiated Amounts in Commercial Arrangement Minimum Savings Rate/Risk Sharing Quality Metrics 33 Quality Metrics-MSSP Different Patient Satisfaction Surveys/Quality Measures

19 Differences between Medicare & Commercial ACOs (cont.) Operational Terms of Contractual Agreements Conditions of Participation with Providers Attribution of Patients Targeted Disease States/Chronic Conditions Demographics of Patient Populations Patient Communications CMS Strict Regulation of Marketing to Beneficiaries Infrastructure/Implementation Process Governance/Waivers

20 Common Goals for Medicare & Commercial Populations Integrated Information Technology & Data Management Coordinated EMR Systems Clinical Data Repositories Call Center Care Delivery Redesign Breakdown silos in Care Continuum/Better Transition Care Provider Engagement (e.g. Patient Compacts) Patient Engagement & Care Management Population Health Management & Analytics Tools Build upon other Physician Alignment Initiatives (e.g. Medical Homes, Bundled Payment)

21 Provider Agreements (David and Panel) Payment Methodologies Shared, Risk or Bundled? Clinical Integration Use of Actuary Per Member/Per Month Governing Board Approval Opt In/Opt Out

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