Medicare Shared Savings Program--Foundation for a Clinically Integrated Network

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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 …

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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  • 1. Page 0May 2014 Prepared for National Rural Health Association Medicare Shared Savings Program Foundation for a Rural Clinically Integrated Network May 2014 ©2014 Pershing Yoakley & Associates, PC. No portion of this PowerPoint presentation may be used for any purpose other than an individual’s own educational purposes without the express written permission of PYA.
  • 2. Page 1May 2014 Prepared for National Rural Health Association • Per se illegal for independent market participants to negotiate jointly on price-related terms • Three options – Messenger model – Economic integration – Clinical integration Antitrust Basics
  • 3. Page 2May 2014 Prepared for National Rural Health Association • Provider organization cannot exercise market power in anti-competitive manner – Market power = immune from competition – Presume market power from market share – Overcome presumption by demonstrating pro-competitive effects Antitrust Basics
  • 4. Page 3May 2014 Prepared for National Rural Health Association • FTC guidance – Statements of Health Care Antitrust Enforcement Policy – Consent decrees and advisory opinions – MSSP safe harbors • Bottom line: Does the organization maintain high degree of interdependence and cooperation to control costs and ensure quality? Clinical Integration
  • 5. Page 4May 2014 Prepared for National Rural Health Association Clinical Integration • Providers accountable to each other and to community to deliver high-quality care in efficient manner – Collectively define and enforce standards of care – Coordinate patient care – Identify and pursue efficiencies • Crucial strategy for value-based purchasing, population health management
  • 6. Page 5May 2014 Prepared for National Rural Health Association Clinically Integrated Network • Lean infrastructure to support provider accountability • Vehicle for independent providers to jointly negotiate with payers – Access to patients – Aggregate risk
  • 7. Page 6May 2014 Prepared for National Rural Health Association • Brings together providers from multiple communities • Unique focus on continuum of care and economies of scale • Aggregate risk • a/k/a Community Care Organizations Rural Clinically Integrated Network
  • 8. Page 7May 2014 Prepared for National Rural Health Association Participation Agreement • Individual providers join a CIN by signing a participation agreement • Terms of agreement established by CIN governing body – Parties’ respective rights and responsibilities – Demonstrates CIN legitimacy to payers • Breach = remedial action, termination
  • 9. Page 8May 2014 Prepared for National Rural Health Association Polling Question #1
  • 10. Page 9May 2014 Prepared for National Rural Health Association CIN Functions • Core functions – Promote evidence-based medicine – Facilitate care coordination – Negotiate and manage payer contracts • Additional support services
  • 11. Page 10May 2014 Prepared for National Rural Health Association Promote Evidence-Based Medicine • EBM = integrating individual clinical expertise with the best available external clinical evidence from systematic research • Clinical protocols – Identify (prioritize) – Implement (education, technology solutions) – Monitor (reporting on quality measures) – Remediation, punitive measures
  • 12. Page 11May 2014 Prepared for National Rural Health Association 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
  • 13. Page 12May 2014 Prepared for National Rural Health Association 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
  • 14. Page 13May 2014 Prepared for National Rural Health Association Shared Savings Programs Key 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
  • 15. Page 14May 2014 Prepared for National Rural Health Association Shared Savings Program Performance • 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
  • 16. Page 15May 2014 Prepared for National Rural Health Association 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 is closing rapidly
  • 17. Page 16May 2014 Prepared for National Rural Health Association • 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
  • 18. Page 17May 2014 Prepared for National Rural Health Association • Shared savings • PQRS reporting • Private payer credibility • Waivers MSSP Advantages
  • 19. Page 18May 2014 Prepared for National Rural Health Association • 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 ACO participation • Three secondary waivers – Patient incentives – Shared savings distributions – Stark law compliance MSSP Waivers
  • 20. Page 19May 2014 Prepared for National Rural Health Association Pre-Participation Waiver • Governing body makes bona fide determination that arrangement reasonably related to MSSP purposes – Includes “promoting accountability,” “managing and coordinating care,” and “encouraging investment in infrastructure and redesigned care processes” • Complete and contemporaneous documentation with public disclosure as required by HHS • Effective through start date of participation agreement or date of application denial letter (with 6 months to unwind)
  • 21. Page 20May 2014 Prepared for National Rural Health Association Participation Waiver • Requirements – Current MSSP participant in good standing – Governing body makes and duly authorizes a bona fide determination that arrangement reasonably related to MSSP purposes – Complete and contemporaneous documentation with public disclosure as required by HHS – Cannot include incentives to limit medically necessary items and services • Timeframe – From effective date through 6 months following expiration or termination of participation agreement (and renewals)
  • 22. Page 21May 2014 Prepared for National Rural Health Association MSSP ACO Formation • Legal entity • Governing body – 75 percent ACO participants – 1 independent Medicare beneficiary – Fiduciary duty (not responsible for governing activities of individuals or entities outside the ACO) • Management – Board-appointed manager – CMO, QA-QI professional, compliance officer – Audit and record retention requirements
  • 23. Page 22May 2014 Prepared for National Rural Health Association • Sufficient number of PCPs to achieve 5,000 attributed beneficiaries • Any other Medicare providers in good standing • “Other entities” MSSP ACO Participants
  • 24. Page 23May 2014 Prepared for National Rural Health Association • Identified by TIN • Includes all providers/suppliers that bill through that provider number (reassignment) • If TIN bills for any primary care service, TIN is exclusive to that ACO MSSP ACO Participant
  • 25. Page 24May 2014 Prepared for National Rural Health Association Required Agreements ACO TIN NPI Accountable Care Organization (CIN) Physician Practice Each Physician Who Reassigns to Physician Practice Participation Agreement Participation Agreement
  • 26. Page 25May 2014 Prepared for National Rural Health Association • Executed prior to submission of application • Explicit agreement to participate in MSSP and adhere to 42 CFR Part 425 • Participants’ rights and obligations • Termination based on non-compliance • No referral requirements Participation Agreement
  • 27. Page 26May 2014 Prepared for National Rural Health Association • 4-physician group practice; each reassigns billing rights to group • Practice can participate in MSSP as part of ACO only if all 4 physicians agree • If practice bills for any primary care service, practice is exclusive to that ACO • Physician can participate in another ACO only if billed through another TIN – Group practice exception • “Other entity” option – Governing body participation Example
  • 28. Page 27May 2014 Prepared for National Rural Health Association • 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 disclosure statements • Job descriptions for required staff • Organizational chart (governance and management) MSSP Application - Details
  • 29. Page 28May 2014 Prepared for National Rural Health Association • Describe how the ACO will: – Establish and maintain quality assurance and improvement program – Promote evidence-based medicine, patient engagement, care coordination, patient-centeredness – Compile and report participants’ quality measure scores – Distribute shared savings and assess shared losses MSSP Application - Narrative
  • 30. Page 29May 2014 Prepared for National Rural Health Association 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
  • 31. Page 30May 2014 Prepared for National Rural Health Association MSSP Attribution – Step 1 • Identify beneficiaries who received a PC service from ACO’s PCPs in last 12 months • Attribute beneficiary to the ACO only if: Total allowed charges for PC services billed by ACO’s PCPs in last 12 months Total allowed charges for PC services billed by PCPs in any other ACO or non-ACO TIN in last 12 months
  • 32. Page 31May 2014 Prepared for National Rural Health Association Step 1 Example Beneficiary Organization PCPs Specialists + Mid-levels A1 ACO $400 $600 A1 Other MSSP ACO $350 $1000 A1 Group Practice $375 $800 Allowed Charges for PC Services
  • 33. Page 32May 2014 Prepared for National Rural Health Association MSSP Attribution – Step 2 • Identify non-Step 1 beneficiaries who received a PC service from an ACO specialist physician within last 12 months • Attribute beneficiary to ACO only if: Total allowed charges for PC services billed by all ACO physicians and mid- levels in last 12 months Total allowed charges for PC services billed by PCPs in any other ACO or non- ACO TIN in last 12 months
  • 34. Page 33May 2014 Prepared for National Rural Health Association 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
  • 35. Page 34May 2014 Prepared for National Rural Health Association • FQHCs • RHCs • CAHs billing Method II billing MSSP Attribution – Rural Considerations
  • 36. Page 35May 2014 Prepared for National Rural Health Association Polling Question No. 2
  • 37. Page 36May 2014 Prepared for National Rural Health Association 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
  • 38. Page 37May 2014 Prepared for National Rural Health Association • Many applicants denied participation due to insufficient attribution • Identifying attributed beneficiaries – Quarterly preliminary assignment lists – Final assignment report at end of the year Attribution Experience
  • 39. Page 38May 2014 Prepared for National Rural Health Association Setting the Benchmarks • Identify all beneficiaries who would have been attributed to ACO in each of 3 prior years • Divide into four categories: ESRD; disabled; elderly dual eligible; elderly non-dual eligible
  • 40. Page 39May 2014 Prepared for National Rural Health Association • Calculate per capita 3-year average total cost of care for each 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 Medicare spending; other updates based to changes to ACO participant list Setting the Benchmarks, Cont’d
  • 41. Page 40May 2014 Prepared for National Rural Health Association CMS Data Requests • At ACO’s request, CMS will provide aggregate claims data for preliminarily assigned beneficiaries • Data enables ACO to identify savings opportunities • No data use agreement or beneficiary notification required because no protected health information
  • 42. Page 41May 2014 Prepared for National Rural Health Association 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 such data sharing – Beneficiary has not exercised opt-out rights
  • 43. Page 42May 2014 Prepared for National Rural Health Association CMS Data Requests CMS also shares aggregate beneficiary reports at the beginning of the start of the agreement period, which include: 1. Aggregated metrics on the assigned beneficiary population 2. Utilization and expenditure data based on historical beneficiaries used to calculate the benchmark
  • 44. Page 43May 2014 Prepared for National Rural Health Association 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, care coordination
  • 45. Page 44May 2014 Prepared for National Rural Health Association 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
  • 46. Page 45May 2014 Prepared for National Rural Health Association PCPs • Incentives to effectively manage patient care • Example: Allocation based on individual PCP’s patient population’s actual total cost of care vs. risk-adjusted target
  • 47. Page 46May 2014 Prepared for National Rural Health Association 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
  • 48. Page 47May 2014 Prepared for National Rural Health Association Specialists • Financial rewards for services to CIN – Defining appropriate use criteria for referral to specialists – Specifying appropriate indications for diagnostic and therapeutic interventions – Establishing performance measures related to specialty care – Developing innovative solutions to enhance communication between PCPs and specialists
  • 49. Page 48May 2014 Prepared for National Rural Health Association • Offset investment • Offset declining revenues Hospital
  • 50. Page 49May 2014 Prepared for National Rural Health Association Per Capita Medicare Spending
  • 51. Page 50May 2014 Prepared for National Rural Health Association Polling Question #3
  • 52. Page 51May 2014 Prepared for National Rural Health Association Martie Ross Pershing Yoakley & Associates, PC 9900 W. 109th Street, Suite 130 Overland Park, KS 66210 913.232.5145 mross@pyapc.com