ACO Final Rule Highlights

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The Accountable Care Organization Final Rule may be a 700-page mammoth, but fear not! This presentation will provide you with the highlights you need to know about the Final Rule, including details on the ACO contract with CMS; information on ACOs and FQHCs, Rural Health Centers and Hospitals; required processes and patient-centered criteria; quality and reporting highlights; application details; and more!

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ACO Final Rule Highlights

  1. 1. ACO Final Rule: Highlights Adele Allison, National Director of Government Affairs, SuccessEHS
  2. 2. What is the ACO Final Rule?
  3. 3. Substantial changes were made to the proposed rules for participating in ACOs. The Final Rule was released on Oct. 20, 2011 .
  4. 4. What is an Accountable Care Organization (ACO)? “Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.”
  5. 5. ACOs Contract with CMS
  6. 6. - Three-year contract term – applies to all stakeholders & participants -Must have sufficient Primary Care Providers and minimum of 5,000 Medicare Physician Fee Schedule beneficiaries
  7. 7. -ACO must be a legal entity with a single TIN (taxpayer identification number) -Must have shared-governance with 75% of ACO participants
  8. 8. - Payment made to ACO TIN – no authority of distribution downstream -PCPs are limited to participation with ONE ACO (Not intended to be punitive; Exclusivity based upon the PCP’s TIN)
  9. 9. - Retain records for 10 years (active ACOs) or 6 years (from date of termination)
  10. 10. FQHCs & Rural Health Centers
  11. 11. <ul><li>Notice of Proposed Rulemaking (NPRM) -> FQHCs and RHCs are ineligible to form ACOs </li></ul><ul><li>UPDATED Final Rule §425.102 – FQHCs and RHCs may form an ACO </li></ul>
  12. 12. <ul><li>Limitation initially due to assignment based on Primary Care Provider (PCP) and claims data </li></ul><ul><li>CMS cross-walked relevant PCP CPTs to Revenue Codes </li></ul>
  13. 13. <ul><li>CMS removed requirement of PECOS number for participation </li></ul><ul><li>FQHCs and RHCs forming ACOs must provide list of PCPs and NPIs who render care at their facilities </li></ul>
  14. 14. ACOs & Hospitals
  15. 15. <ul><li>CMS has established no “ hospital-oriented ” requirements </li></ul><ul><li>ACO does NOT have to have a participating hospital </li></ul>
  16. 16. <ul><li>HOWEVER… </li></ul><ul><ul><li>CAHs billing under Method II may form independent ACO </li></ul></ul>
  17. 17. <ul><li>HOWEVER… </li></ul><ul><ul><li>Hospitals employing ACO professionals </li></ul></ul><ul><ul><ul><li>Can feasibly be the only ACO member of the governing body through employment relationships </li></ul></ul></ul><ul><ul><ul><li>Meet the 75% ACO participant shared-governance requirement </li></ul></ul></ul>
  18. 18. <ul><li>Encourages market consolidation </li></ul><ul><ul><li>Antitrust concerns </li></ul></ul>
  19. 19. Required Processes & Patient-Centered Criteria
  20. 20. <ul><li>ACO Application Required Documentation plans to: </li></ul><ul><ul><li>Promote Evidence-Based Medicine </li></ul></ul><ul><ul><li>Promote Beneficiary Engagement </li></ul></ul><ul><ul><li>Report Internally on Quality and Cost Metrics </li></ul></ul><ul><ul><li>Coordinate Care </li></ul></ul>
  21. 21. <ul><li>Must adopt Patient-Centered focus </li></ul><ul><li>Must promote Patient-Centered care through governance and practice integration </li></ul><ul><li>Strongest evidence will be PCPS that are PCMH recognized </li></ul>
  22. 22. ACO Application & Kick-Off
  23. 23. <ul><li>CMS Applications open Jan. 1, 2012 </li></ul><ul><li>ACO must file NOI </li></ul><ul><ul><li>www.cms.gov/sharedsavingsprogram </li></ul></ul><ul><li>Two Application periods: </li></ul><ul><ul><li>ACOs starting April 1, 2012 </li></ul></ul><ul><ul><li>ACOs starting July 1, 2012 </li></ul></ul>
  24. 24. <ul><li>April 1, 2012 Kick-Off: </li></ul><ul><ul><li>First performance year = 21 months ending Dec. 31, 2013 </li></ul></ul><ul><ul><li>Subsequent performance periods = Calendar Year </li></ul></ul><ul><ul><li>Agreement term = 3 years ending Dec. 31, 2015 </li></ul></ul>
  25. 25. <ul><li>July 1, 2012 Kick-Off: </li></ul><ul><ul><li>First performance year = 18 months ending Dec. 31, 2013 </li></ul></ul><ul><ul><li>Subsequent performance periods = Calendar Year </li></ul></ul><ul><ul><li>Agreement term = 3 years ending Dec. 31, 2015 </li></ul></ul>
  26. 26. Quality & Reporting – Performance
  27. 27. <ul><li>Purpose: To ensure that Quality is not sacrificed in the name of Cost </li></ul><ul><li>33 ACO Quality Performance Standards </li></ul><ul><ul><li>7 related to Patient/Caregiver experience </li></ul></ul><ul><ul><li>3 related to Care Coordination & Patient Safety </li></ul></ul>
  28. 28. <ul><li>33 ACO Quality Performance Standards </li></ul><ul><ul><li>1 calculated from EHR Incentive Program Data </li></ul></ul><ul><ul><li>22 related to At-Risk Populations covering: </li></ul></ul><ul><ul><ul><li>Care Coordination </li></ul></ul></ul><ul><ul><ul><li>Patient Safety </li></ul></ul></ul><ul><ul><ul><li>Preventive Health </li></ul></ul></ul>
  29. 29. <ul><li>33 ACO Quality Performance Standards </li></ul><ul><ul><li>22 related to At-Risk Populations covering: </li></ul></ul><ul><ul><ul><li>At-Risk Populations for Diabetes, Hypertension, IVD, Heart Failure & CAD </li></ul></ul></ul>
  30. 30. Patient / Caregiver Experience
  31. 31. Measure Method of Data Submission Getting Timely Care, Appointments and Information Survey How Well Your Doctors Communicate Survey Patients’ Rating of Doctor Survey Access to Specialists Survey Health Promotion and Education Survey Shared Decision-Making Survey Health Promotion and Education Survey
  32. 32. Care Coordination / Patient Safety
  33. 33. Measure Method of Data Submission Risk-Standardized, All Condition Readmission Claims Ambulatory Sensitive Conditions Admissions: COPD Claims Ambulatory Sensitive Conditions Admissions: CHF Claims % PCPs that Qualify for EHR Incentive Program Payment EHR Incentive Program Reporting Medication Reconciliation: After Discharge from IP GPRO Web-Interface Falls: Screening for Fall Risk GPRO Web-Interface
  34. 34. Preventive Health Measures
  35. 35. Measure Method of Data Submission Influenza Immunization - MU Menu CQM and 2012 EHR-based PQRS GPRO Web-Interface Pneumococcal Vaccination - MU Menu CQM GPRO Web-Interface Adult Weight Screening and Follow-up – MU Core CQM GPRO Web-Interface Tobacco Use Assessment and Cessation Intervention - MU Core CQM and 2012 EHR-based PQRS GPRO Web-Interface Depression Screening GPRO Web-Interface Colorectal Cancer Screening - MU Menu CQM GPRO Web-Interface Mammography Screening - MU Menu CQM GPRO Web-Interface Adults 18+ who had BP Measured in previous 2 years GPRO Web-Interface
  36. 36. At-Risk Populations
  37. 37. Measure Method of Data Submission Diabetes Composite (All / Nothing Scoring): A1c Control (< 8) GPRO Web-Interface Diabetes Composite (All / Nothing Scoring): LDL (<100) GPRO Web-Interface Diabetes Composite (All / Nothing Scoring): BP (<140/90) GPRO Web-Interface Diabetes Composite (All / Nothing Scoring): Tobacco Non-Use GPRO Web-Interface Diabetes Composite (All / Nothing Scoring): Aspirin Use GPRO Web-Interface Diabetes Mellitus: A1c Poor Control (>9) - MU Menu CQM and 2012 EHR-based PQRS GPRO Web-Interface Hypertension: BP Control - MU Menu CQM and 2012 PQRS GPRO Web-Interface IVD: Complete Lipid Profile and LDL Control (<100) - MU Menu CQM and 2012 EHR-based PQRS GPRO Web-Interface IVD: Use of Aspirin or other Antithrombotic - MU Menu CQM and 2012 EHR-based PQRS GPRO Web-Interface Heart Failure: Beta-Blocker Therapy for LVSD - MU Menu CQM GPRO Web-Interface CAD Composite (All / Nothing Scoring): Drug Therapy for lowering LDL-Cholesterol - MU Menu CQM GPRO Web-Interface CAD Composite (All / Nothing Scoring): ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD GPRO Web-Interface
  38. 38. Quality & Other Reporting
  39. 39. <ul><li>Quality Performance Score to include EHR ACO Adoption – Weighted twice as much as other measures </li></ul><ul><li>Phasing in Pay-for-Performance over 3-year contract term </li></ul>Year 1 Year 2 Year 3 # of Measures # of Measures # of Measures Pay-for-Performance 0 25 32 Pay-for-Reporting 33 8 1 Total Measures 33 33 33
  40. 40. <ul><li>Shared-Savings = Must score above 70% on measures </li></ul><ul><li>Starting in 2014 : CMS Certified Vendor required to administer and report patient experience </li></ul><ul><li>Patient Experience + Claims-Based Measures will be reported publicly on “Physician Compare” </li></ul>
  41. 41. <ul><li>Physician Compare site currently live </li></ul><ul><ul><li>www.medicare.gov/find-a-doctor/provider-search.aspx </li></ul></ul>
  42. 42. For more information about industry trends, visit www.successehs.com for white papers, articles, blog posts and more! Click here for our industry blog

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