Medicare Shared Savings Program

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1 Medicare Shared Savings Program Eastern Michigan Chapter of HFMA Insurance and Reimbursement Committee April 30, 2015 Presenter: Kenneth B. Lipan, FHFMA Director of Finance: Clinical Integration, Unified Clinical Organization and Operations Trinity Health System Office

2 What is a MSSP ACO? According to the Centers for Medicare and Medicaid Services (CMS), an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it."

3 Why MSSP? Why Now?

4 Why MSSP? Why Now?

5 Why MSSP? Why Now? Insanity: Doing the same thing over and over again and expecting different results - Albert Einstein

6 What is a MSSP ACO? Only for Medicare Fee-for-Service (FFS) Beneficiaries Not a Plan Medicare beneficiaries enroll in it is a Program in which Providers Participate Doesn t Change how you bill Medicare No Copay Changes for Medicare Beneficiaries Beneficiaries have freedom of choice: still see what ever provider they like

7 How does the MSSP Work? Created a separate Legal Entity Requires you have a minimum of 5,000 Medicare feefor-service attributed lives ACO select to participate in the one-sided or two sided risk model 3-Year Program Commitment 33 Performance Measures, 22 aligned with PQRS Goals are to achieve the Triple Aim: Better Care (quality), Patient Satisfaction, Lower Cost (efficiency and safety) 7

8 One-Sided and Two-Sided Risk Models One-sided risk model has a maximum share of savings of 50% for quality performance with a cap on shared savings Cap on shared savings (10% of benchmark) Two-sided risk model has a maximum share of savings of 60% for quality performance with a cap on shared savings Higher cap on shared savings (15% of benchmark) Shared loss calculation is 1 minus final sharing rate as a function of quality performance (not to exceed 60%) ACOs which meet or exceed the minimum loss rate will share in losses on a first dollar basis All ACOs share in first dollar saved once they meet or exceed MSR

9 Why form a MSSP ACO? Physician Practice Benefits Opportunity to achieve shared savings without putting individual fee-forservice (FFS) reimbursement at risk Receive claims data from CMS on Medicare FFS beneficiaries to improve and better coordinate care Report Physician Quality Reporting System (PQRS) as an ACO, exempting individual physicians from submitting PQRS on your own. Specialists still encouraged to report individually! Avoids PQRS penalty: performance in 2015, payment modification in 2017 (-4% for 10+ EPs, -2% for 1-9 EPs) Hospital can be an equity partner Centers for Medicare & Medicaid (CMS) Definition Facilitates coordination and cooperation among providers to improve the quality of care for FFS beneficiaries and reduce unnecessary costs Promotes accountability for the care of Medicare FFS beneficiaries Encourages investment in infrastructure and redesigned care processes Payment/sharedsavingsprogram/index.html?redirect=/sharedsavi ngsprogram/

10 How Beneficiaries Are Attributed to an ACO 1. Beneficiary must be enrolled in Part A and Part B of fee-for-service (FFS) Medicare for the ENTIRE YEAR a. Any lapse in FFS Medicare coverage excludes the beneficiary b. Any enrollment during the year in Medicare Advantage excludes the beneficiary 2. Beneficiaries can only be assigned to 1 shared savings initiative a. Whichever initiative the beneficiary was assigned to first keeps the patient (e.g. select bundle payment initiatives, demonstration projects) 3. Beneficiary must reside in the US, a US territory or possession 4. Beneficiary must have a primary care service with an ACO physician 5. Beneficiaries must obtain the LARGEST SHARE of their primary care services from the participating ACO a. Primary care services are measured by Medicare allowed charges Highest areas of impact by the ACO and its participating physicians 2014 Trinity Health - Livonia, MI 10

11 How Beneficiaries are Attributed to an ACO Step 1 Beneficiary aligned with at least 1 primary care services is furnished by the PCP in the participating ACO AND More primary care services are furnished by the primary care physicians at the participating ACO than from PCPs at other ACOs or non-aco individual or group TIN Step 2 Beneficiary has NO primary care services from ANY PCP. Alignment is made at least 1 primary care service from a physician (irrespective of specialty) participating in the ACO. AND More primary care services from ACO Professionals (non-pcp physicians in the ACO, NPs, PAs, CNS) at the participating ACO than from any other ACO or non-aco individual or group TIN **CMS reviews each beneficiary's previous 12-months primary care services rendered to update attribution** 2014 Trinity Health - Livonia, MI 11

12 Sample of Evaluation and Management (E & M) Codes used for beneficiary attribution (see Appendix for more details) Office or Other Outpatient Service HCPS/CPT 7 Code Definition New Patient, brief New Patient, limited New Patient, moderate New Patient, comprehensive New Patient, extensive Established Patient, brief Established Patient, limited Established Patient, moderate Establish Patient, comprehensive Established Patient, extensive Initial Nursing Facility Care New or Established Patient, brief New or Established Patient, moderate New or Established Patient, comprehensive 2014 Trinity Health - Livonia, MI 12

13 Assigned Beneficiaries for 3 Typical ACOs Beneficiaries provided at least 1 primary care service by a physician in this ACO (beneficiaries assignable to the ACO) ACO 1 ACO 2 ACO 3 11,839 28,127 24,297 ACO did not provide a plurality of primary care services At least one month of Part A-only or Part B-only coverage 4,008 17,211 6, At least one month in a group health plan At least one month of non-us residence Included in other shared savings initiative Excluded Beneficiaries (total) 4,269 17,882 7,709 Assigned Beneficiaries 7,570 10,245 16, Trinity Health - Livonia, MI 13

14 CMS MSSP Minimum Savings Rate (MSR) Schedule Beneficiaries MSR (low end) MSR (high end) % 3.6% % 3.4% % 3.2% % 3.1% % 3.0% % 2.7% % 2.5% % 2.2% % 2.0% % 2.0% If the MSR is achieved, then the ACO may be eligible to receive first dollar 50% shared savings 14

15 MSSP ACO Shared Saving Performance Source: Health Affairs Blog 1/22/15 McClellan, Kocot and White

16 CMS: Establishment of the Benchmark Use lived attributed to the ACO Distribute the lives into four risk categories: ESRD, Disabled, Aged/Dual eligible and Aged/Non-dual eligible Sum Part A and B claims for the past three years - excluding IME, DSH and pass through costs. Annual cost per beneficiary is truncated at the 99 percentile. Weight the prior year's claims: 60% most recent, 30% two years ago and 10% three years ago then trend the result forward Risk adjust the results using the CMS Hierarchical Condition Category (HCC)

17 Distribution of Shared Savings Rates Source: Health Affairs Blog 1/22/15 McClellan, Kocot and White

18 Shared Savings by State Source: Health Affairs Blog 1/22/15 McClellan, Kocot and White

19 Relationship Between Saving and Quality Score Source: Health Affairs Blog 1/22/15 McClellan, Kocot and White

20 ACO-33 Quality Measures & Scoring Methodology Domain Patient/Caregiver Experience Care Coordination/Patient Safety Number of Measures Total Measures for Scoring Purposes 8 8 individual CAPHS survey measures i.e. Press Ganey 10 9 measures + EHR measure double weighted (4 points) Possible Points Domain Weight 16 25% 22 25% Preventive Health 8 8 measures 16 25% Clinical Care for At-Risk Population 7 5 individual measures + 2-component diabetes composite measure scored as % Total in all Domains %

21 ACO-33 Quality Measures & Scoring Methodology Year 1 All measures are pay for reporting Year 2 Performance and reporting based on Phase-In Schedule Year 3 Performance and reporting based on Phase-In Schedule

22 Appendix: Quality Performance

23 ACO-33 Quality Measures & Scoring Methodology (1 of 3)

24

25 ACO-33 Quality Measures & Scoring Methodology (3 of 3)

26 Example of How Scoring Works There are eight individual measures for the patient/caregiver experience of care domain. 1. If an ACO achieves a significant quality increase in all eight measures then the ACO would be awarded the maximum of four bonus points for this domain. However. 2. If the ACO achieved a significant quality increase in only one of the eight measures in this domain and no significant quality decline on any of the measures then the ACO would be awarded bonus points for quality improvement in the domain that is 1/8 times 4 = The total points that the ACO could achieve in this domain could not exceed the current maximum of 16 points.

27 How MSSP Benchmarking Works Benchmarks set for two years, and may be based on up to three years of data starting in Collection Reporting Payment & , 2013, & , 2015, & 2019 Flat percentage benchmarks will be used when the 90 th percentile performance is greater than 95% (even ratios). Up to 4 bonus points per domain for improvement, but cannot exceed total achievement points available. Based on MA Star rating system Points awarded if statistically significant net improvement

28 CMS Definitions Terms used on CMS generated reports and communications ACO Participants: Individuals or groups of Medicare-enrolled providers or suppliers as identified by a TIN ( ) Examples: Acute Care Hospital, Group Practice, Individual Practice, SNF, ER, Critical Access Hospital ACO Provider/Supplier: A provider or supplier that bills for items and services it furnishes to Medicare FFS beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations. Examples: Physicians, Nurse Practitioners, pharmacists, PT/OT, Clinical Nurse Specialists (CNS) who bill through an ACO Participant Trinity Health - Livonia, MI 28

29 CMS Definitions continued ACO Professional: Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialists (CNS) Primary Care Physician: General Practice Internal Medicine Family Practice Geriatric Medicine Terms used on CMS generated reports and communications 2014 Trinity Health - Livonia, MI 29

30 Appendix: Beneficiary Attribution and Other Resources 2014 Trinity Health - Livonia, MI 30

31 Primary care codes included in beneficiary assignment criteria (1 of 6) Office or Other Outpatient Service HCPS/CPT 7 Code Definition New Patient, brief New Patient, limited New Patient, moderate New Patient, comprehensive New Patient, extensive Established Patient, brief Established Patient, limited Established Patient, moderate Establish Patient, comprehensive Established Patient, extensive Initial Nursing Facility Care New or Established Patient, brief New or Established Patient, moderate New or Established Patient, comprehensive 2014 Trinity Health - Livonia, MI 31

32 Primary care codes included in beneficiary assignment criteria (2 of 6) Subsequent Nursing Facility Care HCPS/CPT 7 Code Definition New or Established Patient, brief New or Established Patient, limited New or Established Patient, comprehensive New or Established Patient, extensive Nursing Facility Discharge Services New or Established Patient, brief New or Established Patient, comprehensive Other Nursing Facility Services New or Establish Patient 2014 Trinity Health - Livonia, MI 32

33 Primary care codes included in beneficiary assignment criteria (3 of 6) Domiciliary, Rest Home or Custodial Care Services HCPS/CPT 7 Code Definition New Patient, brief New Patient, limited New Patient, moderate New Patient, comprehensive New Patient, extensive Established Patient, brief Established Patient, moderate Established Patient, comprehensive Established Patient, extensive 2014 Trinity Health - Livonia, MI 33

34 Primary care codes included in beneficiary assignment criteria (4 of 6) Domiciliary, Rest Home or Home Care Plan Oversight Services HCPS/CPT 7 Code Brief Definition Comprehensive 2014 Trinity Health - Livonia, MI 34

35 Primary care codes included in beneficiary assignment criteria (5 of 6) Home Services HCPS/CPT 7 Code Definition New Patient, brief New Patient, limited New Patient, moderate New Patient, comprehensive New Patient, extensive Established Patient, brief Established Patient, moderate Established Patient, comprehensive Established Patient, extensive 2014 Trinity Health - Livonia, MI 35

36 Example: Assignment based on highest allowed charges for primary care services Allowed Charges for Primary Care Services Beneficiary Organization ID PCP ACO Professional A1 A9999 $454 $654 A $300 $1,900 A $250 $2,500 Beneficiary A1 is assigned to ACO A9999 because A9999 had the highest allowed charges for primary care services ($454) even though two other non-aco practices had higher allowed charges provided by ACO professionals 2014 Trinity Health - Livonia, MI 36

37 Materials Being Sent to Beneficiaries On Behalf of your Practice (refer to your packet) Beneficiary Notice Letter Personal Health Information Declination Form (Opt-Out of sharing PHI) Accountable Care Organization Frequently Asked Question Document NOTE: You can refer beneficiaries who inquire about the program to call the ACO toll-free number A member of the team will get back to them within 72 hours (3 business days). FYI: You will receive a bound copy of the materials for your office to Use with beneficiaries during their initial visit after the notice is sent

38 Must Reads That Aren t Textbooky Nudge: Improving Decisions About Health & Happiness by Cass Sunstein Happiness/dp/ X.except for this one which is a staple had to include it The Social Transformation of American Medicine by Paul Starr &sr=1-1&keywords=social+transformation+of+american+medicine 2015 Trinity Health - Livonia, MI

39 References and links to important reading materials Medicare Shared Savings Program Shared Savings and Losses and Assignment Methodology Specifications Section 3: Beneficiary Assignment for Medicare Shared Savings Program Payment/sharedsavingsprogram/Downloads/Shared-Savings-Losses-Assignment-Specv2.pdf Premier/Trinity Health Collaborative Poster, MSSP Attribution Methodology Decision Tree PPT for mass printing 2014 Trinity Health - Livonia, MI 39

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