ACO Essentials Series

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1 ACO Essentials Series How to Use Health Endeavors Technology January, /11/2017 1

2 Agenda Day 1&2 Interactive Analytic Tools Define ACO Goals- Success Plan Organizational Structure Executive TIN and Provider Quality and Financial Performance Dashboard Drill Down - HCC Patient Risk Stratification Aggregate Expenditure & Utilization Comparison Tool Comprehensive Care Joint Replacement (CJR) - Episode of Care Out-of-Network Trends from In-Network Provider Financial Scorecard (Automated Distribution) Provider Quality Scorecard (Automated Distribution) Where is your ACO today against benchmark? Benchmark Analysis Tool Total Quality Score 1/11/2017 2

3 Agenda Day 3, 4 and 5 Shared Savings Strategies Provider Financial & Quality Scorecards ( Distribution) ACO Modeling (MACRA/MIPS/APM) Which Track is best for your organization? PHIT Analysis Reports Review Patient Profile (Gaps in Care) EMR Integration Patient Master Dashboard GPRO 2017 Chronic Care Management (CCM) CJR Patient Reported Outcomes 1/11/2017 3

4 Triple Aim Improve Patient Experience Improve population health Reduce cost of healthcare Clinically Integrated Network (CIN) Quality Population Health Management MACRA Compliance MIPS APM Quality Improvement Program GPRO/PQRS Disease & Wellness Gaps in Care EHR Gap Analysis Patient Engagement Provider Participation Control Out-of- Network Migration CCM Annual Wellness Visit After Hours Program/ER Alternatives Specialist Outreach Clinics (Access to Care) Redirect Out-of-Network Spend Preventive Care Services (Gaps in Care) Missed Revenue Opportunity Achieve Shared Savings Targeted Spend Reduction What is your historical benchmark? Stop the Admit Visit Stop the ER Visit Preventive Care Services (Gaps in Care) Patient Case Management (CCM 99490) Patient Follow-up & Education Aggregate Expenditure & Utilization Trends Re-admit, ED, MRI, CT, Home Health 1/11/2017 4

5 2 Requirements to achieve Shared Savings Successful Quality Measure Reporting & Benchmark Performance Reduce spending by at least 5% (or a greater % than MSR) 1/11/2017 5

6 How does our ACO know if we are on track for Shared Savings? Quarterly Benchmark Tool Analysis Aggregate Expenditure PPPY vs. Historical Benchmark Total QM Score Calculator Quality Performance Scoring NPI Level TIN/NPI Benchmark Analysis Actual Benchmark vs. Goal Benchmark (based on Historical Spend) NPI Level 1/11/2017 6

7 Provider Financial & Quality Scorecards Distribution Financial Benchmark TIN/NPI Quality Performance TIN/NPI Quality Progress TIN/NPI 1/11/2017 7

8 Triple Aim Improve Patient Experience Improve population health Reduce cost of healthcare Clinically Integrated Network (CIN) Quality Population Health Management MACRA Compliance MIPS APM Quality Improvement Program GPRO/PQRS Disease & Wellness Gaps in Care EHR Gap Analysis Patient Engagement Provider Participation Control Out-of- Network Migration CCM Annual Wellness Visit After Hours Program/ER Alternatives Specialist Outreach Clinics (Access to Care) Redirect Out-of-Network Spend Preventive Care Services (Gaps in Care) Missed Revenue Opportunity Achieve Shared Savings Targeted Spend Reduction What is your historical benchmark? Stop the Admit Visit Stop the ER Visit Preventive Care Services (Gaps in Care) Patient Case Management (CCM 99490) Patient Follow-up & Education Aggregate Expenditure & Utilization Trends Re-admit, ED, MRI, CT, Home Health 1/11/2017 8

9 Shared Savings Strategies Assign all patients to NPI level Quick Report: Attributed Patient Assignment Requires Attention Stop Patient Churn/Turnover Quick Report: Beneficiary Turnover Analysis (Churn) Schedule Medicare Wellness Visit Schedule CCM /11/2017 9

10 Shared Savings Strategies Out-of-Network (NPI MGMT) Quick Report: Configure Division, TIN & NPI Map NPI Management Tool Quarterly/Monthly Quick Reports Attributed Patient Assignment Requires Attention Beneficiary Turnover Analysis (Churn) Configure Division, TIN & NPI Map 1/11/

11 Shared Savings Strategies Executive Dashboard (Monthly/Quarterly) Verify patient assignment to TINs Review unassigned (Attributed patient assignment requires attention quick report) Executive Dashboard (Monthly) Potentially Costly: enroll patients in CCM program or medication management program. See other Tiers (Risk Quick Report) Executive Dashboard (Monthly) Risk Score: determine tiers of focus. Risk Score: enroll patients in CCM program or medication management program. e.g.; Risk (HCC) Score change greater than 10% increase Enroll CCM /11/

12 Patient Risk Stratification Tiers Tier One: Top 30% HCC this year or prior year 3+ Chronic Conditions 2+ Hospital Admission in 12 months or 3+ ED Visits in 24 months Tier 2 1+Chronic Conditions 3+Current Medications Info columns only: Post Acute Claim in last 24 months (HHA, SNF, IRF) - Y/N Annual Wellness visit last 12 months - Y/N HCC Score Medications prescribed but not filled Tier 3 Hospital Discharge in past 6 months 1+Current Medications Info columns only: Post Acute Claim in last 24 months (HHA, SNF, IRF) - Y/N Annual Wellness visit last 12 months - Y/N HCC Score Medications prescribed but not filled Health Endeavors Copyright

13 Shared Savings Strategies Executive Dashboard (Monthly) Spend Increase: determine tiers of focus Spend Increase: run aggregate expenditure interactive tool comparisons for NPI and TIN to determine spend reduction focus areas. (Pull aggregate expenditure flat excel file). e.g.; 2015 vs spend change greater than 0.00%. find spend target areas in aggregate expenditure tool. Financial & Quality Scorecards (Monthly Distribution) Setup financial benchmark (5%) reduction and quality performance score distribution to all TIN practice managers and NPI providers. QM Performance Scoring & QM Progress (Monthly) Review Scores of TINs/NPIs to determine substandard performance on scoring or progress. Face-to-Face Meeting with practices and/or individual providers with Spend Increase or substandard Quality Performance. (Monthly) Spend Increase: determine tiers of focus Use scorecards and aggregate expenditure tool to assist you in the discussion Focus on quality and financial targets. 1/11/

14 Tier Determination TIN and NPI (Resource/Structure Dependent) Risk (HCC) Score change greater than 10% increase 2015 vs spend change greater than 0.00%. <L Spend Tiers Greater than zero % - Highest to Lowest with emphasis on NPIs with highest number of Costly Patients -5% 0% to 10% -10% -5% -15% -10% -20% -15% HCC Tiers Greater than 10% - Highest to Lowest change increase with emphasis on NPIs with highest number of Costly Patients 1/11/

15 Shared Savings Strategies HCC Comparison Tool (Monthly) Potentially Costly Under Review/Resolved Enroll CCM Program Comprehensive Care Joint Replacement (CJR) (Monthly) Complications Trending Discharge Trending Length of Stay Complications Daily Average Cost Target Price vs. Actual Spend Out-of-Network Trending (Monthly) OON DRG Focus OON Provider Focus HCC Audit (Annual or change in billing company/ehr) Billing Company Physician/Staff patient-level audit and education 1/11/

16 HCC Coding Audit Every Provider Capture the HCC Diagnosis Codes Patient Superbill Diagnosis Codes ICD10-1 ICD10-2 ICD10-3 ICD10-4 Billing Company Submission of Diagnosis Codes ICD10-1 ICD10-2 Missing Code Missing Code Not capturing the codes results in lower HCC score for patient and lower benchmark for ACO. Takes minimum of 12 months for this to create impact on your benchmark. Compare your office Superbill to Patient Profile for 10 Charts. 52% of ACOs have encountered this issue. Health Endeavors Copyright

17 Shared Savings Strategies Aggregate Expenditure Analysis (Monthly) Discharges 30 day all cause readmissions Computer Tomography CT Events Durable Medical Equipment Emergency Department Visits Emergency Department Visits that lead to hospitalizations Home Health (lower not always good) Hospice (lower not always good) MRI SNF Specialists 1/11/

18 ED Visits ED Visits lead to Hospitalization 30 day All Cause Re-admissions Targets CT/MRI Hospital Discharges Health Endeavors Copyright

19 ED Visits ED Visits lead to hospitalization All Cause Re-Admissions Strategies Hospital Discharges Patient Case Management & Care Coordination --TCM and Program Patient Follow-up and Education --CCM Program Disease Focused Interventions --Annual Wellness Visit Scheduling Initiative --Automated Preventive Care Alerts Disease & Wellness Gaps in Care After Hours Program/ER Alternatives Trending - Direct Correlation to Potentially Costly Patients Health Endeavors Copyright

20 MORE SHARED SAVINGS STRATEGIES 1/11/

21 Define Specialist Network 21

22 Out-of-Network Migration Formulate In-Network Referral Program Health Endeavors Copyright

23 Excessive Home Health Visits 4 or more home health episodes within a 24 month period Health Endeavors Copyright

24 Shared Savings Strategies ACO Distribution Model Example Distribution Criteria TIN Benchmark Quality Measures Patient Survey Results Example Distribution Point System 2 met benchmark 1 did not meet benchmark 2 successful reporting of quality measures to ACO 0 did not successfully reporting quality measures to ACO 2 Satisfied successful percentage per CMS Standards 0 Did not satisfy the percentage per CMS Standards. 10% to 20% holdback for infrastructure of ACO and Care Coordination. Pro-Rated by Attributed Lives. EMR Use and Integration Leadership and Participation 2 stage 2 MU attestation 1 stage 1 MU attestation 0 no stage 1 MU attestation 2 took on leadership role 1 participated on committee 0 no leadership or committee involvement Health Endeavors

25 2017 Quality Metrics CAHPS/Claims-Based/GPRO Central Repository 25

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29 Quality Metrics Data Imports Central Repository CCLF (claims) Monthly Imports EHR Integration (Extract, Load, Transform ETL) EHR Builds (Custom or EMR BRD) xls, xlsx, txt, csv XML CCDA Health Endeavors Single/Spec File Upload Tool Manual Key 29

30 Manual Key Claims (CCLF) Data Imports Health Endeavors Spec or Spec File Upload EHR Extract, Transform, Load [Automation] Lab File HL7 v2 (parsed with multi delimiters) and HL7 v3 (xml) GPRO Central Repository Data Imports HE Business Requirements Document (EHR BRD) Builds (xlx, xlxs, txt, csv) 30

31 Audit Changes 2017 Regulatory Updates 31

32 32 GPRO Web Interface: Quality Measures Validation Audit ACO, Measure, and Beneficiary Selection Shared Savings Program ACOs may be selected for audit In 2016, 10% of the SSP ACOs will be selected for audit Selection will be random or based on data anomalies Anomalies include such things as unusually high skip rates due to Medical Record Not Found Audit Measure and Beneficiary Selection CMS will audit about 200 records per ACO, across 4 to 5 measures All records will be reviewed by CMS Pioneer and Next Generation Model ACOs Information on the 2016 QMV Audit will be provided in the Pioneer Briefing and the Next Generation ACO Newsletter

33 33 GPRO Web Interface: Quality Measures Validation Audit, Process and Impact At the end of the audit, CMS will provide education and feedback regarding the findings. CMS will calculate the overall match rate Overall match rate = 100% Number of matches Number of records audited If the overall match rate is < 90%, the ACO s overall quality score may be reduced proportional to the ACO s Quality Measures Validation Audit match rate, and thus may impact financial reconciliation Example: If ACO earns an overall quality score of 95.00% and has a Quality Measures Validation Audit match rate of 80.00%, their final overall quality score used in financial reconciliation may be reduced to 95.00% 80.00% = 76.00% Please follow the Shared Savings Program ACO Spotlight Newsletter for information on an upcoming QMV Audit Webinar on January 9, Pioneer and Next Generation Model ACOs Please follow the Pioneer Briefing and the Next Generation ACO Newsletter for information on upcoming QMV Audit Webinars.

34 MSSP Track 1 (3 year current Medicare contract Renewal) MSSP Track 1+ TBD MSSP Track 2 MSSP Track 3 Next Generation ACO Strategic Planning ACO MODELING (MACRA/MIPS/APM) WHICH TRACK IS BEST FOR YOUR ORGANIZATION? 34

35 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Shared Savings Yes TBD Yes Yes Yes Shared Losses No TBD Yes Yes Yes Summary of risk model This track is designed for lessexperienced organizations. Participants share in savings but not losses. TBD More experienced organizations may bypass Track 1 and begin in Track 2. ACOs that begin in Track 1 can move to Track 2 after three years. Track 2 participants share in both savings and losses. This track began in 2016 and has a higher sharing rate than Tracks 1 and 2. Organizations can share in savings up to 75 percent. They are also at risk for greater losses than organizations in Track 2. Increased shared risk: For periods one through three, organizations would share savings or losses up to 80 percent; for period four, the rate would increase to 85 percent. Full performance risk: Organizations would share 100 percent of the savings and losses. 35

36 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Shared Savings Rate Up to 50% TBD Up to 60% Up to 75% 80% or 100% depending on arrangement choice Shared loss Rate N/A TBD May not be less than 40% or exceed 60% Quality scoring Maximum Sharing Cap Final sharing rate conditional on quality performance Payment capped at 10% of ACO s benchmark TBD TBD Final sharing rate conditional on quality performance Payment capped 15% of ACO s benchmark May not be less than 40 percent or exceed 75% Final sharing rate conditional on quality performance Payment capped at 20% of ACO s benchmark 80% or 100% depending on arrangement choice Final sharing rate NOT affected by quality rating Payment capped at 15% of ACO s benchmark 36

37 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Risk? No downside risk Little financial incentive to change. Create your own internal financial incentive to change. TBD Potential for downside risk. Risk may incentivize more proactive population change. Create your own internal financial incentive to change. More potential for downside risk. Risk may incentivize more proactive population change. Create your own internal financial incentive to change. Most potential for downside risk. Risk may incentivize more proactive population change. Create your own internal financial incentive to change. Minimum Savings Rate (MSR) Minimum Loss Rate (MLR) 2% to 3.9% depending on number of assigned beneficiaries TBD Choice of symmetrical MSR/MLR: (i) no MSR/MLR; (ii) symmetrical MSR/MLR in 0.5% increment between 0.5% - 2.0%; (iii) symmetrical MSR/MLR to vary based upon number of assigned beneficiaries (as in Track 1) Choice of symmetrical MSR/MLR: (i) no MSR/MLR; (ii) symmetrical MSR/MLR in 0.5% increment between 0.5% - 2.0%; (iii) symmetrical MSR/MLR to vary based upon number of assigned beneficiaries (as in Track 1) Applies a discount to benchmark instead of having an MSR. First dollar shared savings and losses for spending below or above the benchmark, respectively. 37

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39 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Benchmark Resetting benchmark at the start of its 2 nd or subsequent agreement period. Equal weighting of historical benchmark years not the 10/30/60. TBD Resetting benchmark at the start of its 2 nd or subsequent agreement period. Equal weighting of historical benchmark years not the 10/30/60. Resetting benchmark at the start of its 2 nd or subsequent agreement period. Equal weighting of historical benchmark years not the 10/30/60. One year benchmark is always discounted 0.5% - 4.5%, making it harder to achieve additional savings. Benchmark and Performance year expenditures Payment amounts included in Parts A and B FFS claims using a 3 month claims run out with a completion factor --excluding IME and DSH payments Payment amounts included in Parts A and B FFS claims using a 3 month claims run out with a completion factor --excluding IME and DSH payments Payment amounts included in Parts A and B FFS claims using a 3 month claims run out with a completion factor --excluding IME and DSH payments Payment amounts included in Parts A and B FFS claims using a 3 month claims run out with a completion factor --excluding IME and DSH payments Payment amounts included in Parts A and B FFS claims using a 3 month claims run out with a completion factor --excluding IME and DSH payments 39

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41 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Contract Length But can withdraw? 3 years Renewal for additional 3 years Withdraw available TBD 3 years Withdraw available Once elected, ACO cannot go into Track 1 for subsequent agreement periods 3 years Withdraw available Once elected, ACO cannot go into Track 1 for subsequent agreement periods The Model will consist of three initial performance years and two optional one-year extensions Withdraw available Very difficult to get application approval if independent physician-based (e.g., IPA) Assignment Preliminary Prospective for reports; retrospective for financial reconciliation TBD Preliminary prospective assignment for reports; retrospective assignment for financial reconciliation Prospective assignment for reports, quality reporting and financial reconciliation Prospective assignment for reports, quality reporting and financial reconciliation 41

42 SNF 3 Day Rule Wavier MACRA Impact 42

43 Criteria Consideration MSSP Track #1 MSSP Track #1+ MSSP Track #2 MSSP Track #3 NextGen Payment and Program Rule Waivers under Part 425 N/A N/A N/A May apply for a waiver of the SNF 3 Day Rule May apply for a waiver of the SNF 3 Day Rule MACRA APM subject to MIPS adjustments +/- 4% /- 5% /- 7% /- 9% TBD Advanced APM 5% Incentive Payment 2026 Higher Physician Fee Schedule Advanced APM 5% Incentive Payment 2026 Higher Physician Fee Schedule Advanced APM 5% Incentive Payment 2026 Higher Physician Fee Schedule 43

44 Comprehensive Care Joint Replacement (CJR) Regulatory updates CEHRT Track Advanced APM designation Only for entities that meet APM Threshold. SNF 3 Day Rule Wavier 44

45 Summary of Recommendations current Track 1 MSSP (CJR Mandatory)- Low Risk Elect CEHRT Track for Comprehensive Care Joint Replacement (CJR) for 2017 to obtain Advanced APM status. Requires financial arrangements list for collaborators. 5% Incentive Payment and 2026 higher Physician Fee Schedule. Need to determine if TINS meet the threshold to be qualified practitioners under the incentive. Waiver of SNF 3 Day Rule for years 2 through 5 of CJR program for specific SNFs. Renew in Track 1 ACO for a subsequent 3 year term. Implement internal financial penalties as if in Track 3 for nonperforming TINs and NPIs. (see ACO Distribution Model) 45

46 Summary of Recommendations Current Track 1 MSSP (CJR Mandatory)- Higher Risk Elect CEHRT Track for Comprehensive Care Joint Replacement (CJR) for 2017 to obtain Advanced APM status. Requires financial arrangements list for collaborators. Waiver of SNF 3 Day Rule for years 2 through 5 of CJR program for specific SNFs. Renew in Track 3 ACO for a subsequent 3 year term. Provides ability to select a lower benchmark than MSSP Track 1 ACO. Prospective assignment (not preliminary) for reports, quality reporting and financial reconciliation; e.g. improve tracking assigned population. (not available in Track 1 or 2). Waiver of 3 day SNF. 5% Incentive Payment and 2026 higher Physician Fee Schedule. Need to determine if TINS meet the threshold to be qualified practitioners under the incentive. 46

47 Contact Us Kris Gates, CEO 1/11/