Rural Accountable Care: Here to There


Published on

Published in: Health & Medicine, Business
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Key distinction is that the 1 primary care service has to be from an ACO participating physician (not a primary care physician, but not a NP, PA, or CNS either). NPs, Pas, and CNs fall into the ACO Professional category.
  • Rural Accountable Care: Here to There

    1. 1. Page 0Rural Accountable Care:Here to ThereNational Rural Health Association2013 Annual MeetingMartie Ross, PrincipalPershing Yoakley & Associates, PC
    2. 2. Page 1• 250-approved MSSP ACOs– 4 million attributed Medicare beneficiaries– 10 percent include rural component– 2014 application process now under way• Around 200 commercial ACOs – and growing– Negligible rural activity• Slightly more physician-led ACOsEnvironmental Scan
    3. 3. Page 2
    4. 4. Page 3Elliott Fisher’s 2006 MedPAC presentation• Higher spending regions experience lower quality andsatisfaction• Differences in spending = supply sensitive services• “No one is accountable for local capacity and politicalculture.”• Create 5,000 extended hospital medical staffs accountablefor care for defined population– Payment adjustments based on performance measurements
    5. 5. Role of Community HospitalTodayTodayPillar of thecommunityEnsure essentialemergent and acutecareservices, subsidizewith profitableoutpatient servicesPhysicianrecruitmentand retentionMaximizeavailability ofhealth careservices in thecommunity
    6. 6. Role of Community HospitalTomorrowTodayResponsibility forentire carecontinuum,regardless of whereand by whom careis deliveredFuture payment tiedto assumingresponsibility forcovered livesPopulationHealthManagement
    7. 7. Page 6Transitional modelTODAY: Volume-based reimbursement→ Accountable careTOMORROW: Value-based reimbursementAccountable Care Economics
    8. 8. Page 7• Begin shifting risk from payer to provider• ACO is risk management vehicle• ACO risk = total FFS payments – benchmark– Held accountable for quality of care by performance standards• HMO risk = provider cost – capitated paymentAccountable Care Economics
    9. 9. Page 8• Actual total FFS payments– Payer’s actual total payments for specified servicesprovided to identified patient population during definedtime period– All providers, not just ACO participants• Benchmark– Predetermined target spend for exact same services,population, and time period– Typically based on historical dataAccountable Care Economics
    10. 10. Page 9• Performance standards– Predetermined broad-ranging quality measures– Overall patient care – not limited to ACO participants– Payment and continued participation tied to overall ACOperformanceAccountable Care Economics
    11. 11. Page 10One-Sided vs. Two-Sided• One-Sided - If actual costs exceedbenchmark, ACO not liable for difference• Two Sided - If actual costs exceedbenchmark, ACO liable for difference– Eligible for greater share of savings• Window of opportunity on One-Sided model isclosing rapidly
    12. 12. Page 11Shared 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
    13. 13. Page 12Shared Savings ProgramPerformance• Providers continue to bill fee-for-service• Track performance on quality metrics• Calculate payer’s actual total cost of care• Actual – benchmark = savings• Payer pays ACO percentage of savings• ACO distributes pool to participants• Adjust benchmark, start over
    14. 14. Page 13• 250 participating ACOs• Three-year contracts– Each year = performance year– One-sided available first contract term only• Next start date is January 1, 2014– NOI due May 31– Application due July 31Medicare Shared Savings Program
    15. 15. Page 14MSSP ACO Formation• Legal entity• Governing body– 75 percent ACO participants– 1 independent Medicare beneficiary– Fiduciary duty (not responsible for governingactivities of individuals or entities outside the ACO)• Management– Board-appointed manager– CMO, QA-QI professional, compliance officer– Audit and record retention requirements
    16. 16. Page 15MSSP AttributionPrimary Care Services• E&M Services– 99201-15; 99304-99318;99324-99340; 99341-99350• Wellness Visits– G0402, G0438, G0439• RHC/FQHC Services– 0521, 0522, 0524, 0525Primary Care Physicians• Family Practice• General Practice• Internal Medicine• Geriatric Medicine
    17. 17. Page 16MSSP 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
    18. 18. Page 17MSSP 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
    19. 19. Page 18Beneficiary EligibilityDuring 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
    20. 20. Page 19– Shared savings in a cost-reimbursed/fixed costfinancial model– Complexity of attribution model– Upfront investment, impossible to calculate ROI– Technical assistanceDoes the Model Work for Rural?
    21. 21. Page 20• What do we really want to achieve?• Criteria– Support rural physicians in adopting evidence-based medicine– Provide outpatient care coordination– Seamless transfers between levels of care– Right size services (volume vs. fixed costs)• Option: Rural clinically integrated network, or RCINWhat Model Would Work?
    22. 22. Page 21Rural Clinically IntegratedNetwork - RCIN•Providers accountable toeach other and to thecommunity to deliver high-quality care in efficientmanner-Collectively define andenforce standards of care-Coordinate patient care
    23. 23. Page 22• Per se illegal for independent market participantsto negotiate jointly on price-related terms• Three options– Messenger model– Economic integration– Clinical integrationAntitrust Basics
    24. 24. Page 23• Independent provider organization cannotexercise market power in anti-competitivemanner– Market power = immune from competition– Presume market power from market share– Overcome presumption by demonstrating pro-competitive effectsAntitrust Basics
    25. 25. Page 24• FTC guidance– Statements of Health Care Antitrust EnforcementPolicy - Physician Network Joint Venture– Advisory opinions (Norman, OK)– MSSP safe harbors• Bottom line: Does organization maintain highdegree of interdependence and cooperation tocontrol costs and ensure quality?Clinical Integration
    26. 26. Page 25Clinical 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
    27. 27. Page 26Clinically Integrated Network• Lean infrastructure to support provideraccountability• Vehicle for independent providers tocentralize certain functions and operations– Access to patients– Access to payment– Access to actionable information
    28. 28. Page 27Participation 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
    29. 29. Page 28CIN Functions• Core functions– Promote evidence-based medicine– Facilitate care coordination– Negotiate and manage payer contracts• Additional support services
    30. 30. Page 29Promote Evidence-Based Medicine• EBM = integrating individual clinical expertisewith the best available external clinical evidencefrom systematic research• Clinical protocols– Identify (prioritize)– Implement (education, technology solutions)– Monitor (reporting on quality measures)– Remediation, punitive measures
    31. 31. Page 30Facilitate Care Coordination• Identify high-risk, high-cost patients– Disease registries– Data analytics (claims data)• Aggressive interventions– Patient navigator– Remote monitoring– Transitional care management– Health information exchange
    32. 32. Page 31• “Regionalization” of programs• Tertiary careFacilitate Care Coordination
    33. 33. Page 32Manage Payer Contracting• Standard fee schedule• Narrow networks and tiered benefits plans• Pay for performance (FFS enhancements)• Shared savings programs• Bundled payments• Centers of Excellence• Global budgets
    34. 34. Page 33
    35. 35. Competitive CollaborationMaintain access throughappropriate resourceallocationMaintain local decision-making to fullest extentpossible
    36. 36. Traditional Rural Health NetworkPurpose• Administrative simplification• Economies of scaleExamples• Joint purchasing of products andservices• Shared information technology• Joint recruitment/sharedpersonnel• Staff education• Peer support for governance andmanagement• Credentialing, peerreview, utilization review• Quality/performanceimprovement activities• Access to grant funding
    37. 37. Organizational CommitmentGovernance structure- All participants have a voice- Clear decision-making processSustainability- Operating account, financialcommitment, and contributions;financial reportsPractical matters- Personnel; real and personalproperty; limitation of liability;indemnification; dispute resolution;terminationCommitment
    38. 38. Operational CommitmentQualityimprovementplanStrategic plan OperationalplanEducationplan- Paymentand deliverysystemreform- Needs andassetsassessment-Measures forsuccess- Identifyspecificactivities to be“regionalized”- Identifyparticipants (&respectiveroles)- Task list toachieve each“regionalized”activity- Necessary andavailableresources- Timelines
    39. 39. Page 38• Educate board, management team, physicians• Conduct brutally honest community health needsassessment• Identify and evaluate potential affiliationsImmediate To-Do List
    40. 40. Page 39Martie Rossmross@pyapc.com9900 W. 109th Street, Suite 130Overland Park, KS 66210(913) 232-5145Learn more about PYA at