Medicare Final Accountable Care Organization (ACO) Regulations Effective January 1, 2012 Median Savings of $470 Million over 4 Years

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1 October 20, 2011 CIT Healthcare, John M. Cousins, SVP Healthcare Intelligence Tel: Cell: Medicare Final Accountable Care Organization (ACO) Regulations Effective January 1, 2012 Median Savings of $470 Million over 4 Years The Centers for Medicare and Medicaid Services (CMS) released final regulations that would implement the Medicare Shared Savings Program (Shared Savings Program) created by the Affordable Care Act. This program provides incentives for physicians and hospitals to create accountable care organizations (ACOs) that would enter into an agreement with Medicare to take responsibility for improving quality and coordination of care for a group of at least 5,000 beneficiaries, while lowering their costs, in return for a share of the resulting savings. CMS estimates a total aggregate median impact of $470 million in net Federal savings for CYs 2012 through 2015 from the implementation of the Shared Savings Program down from the proposed regulations estimate of $510 million over a 3 year period. The 10th and 90th percentiles of the estimate distribution, for the same time period, show net savings of $0 million and $940 million Background: Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an Accountable Care Organization (ACO) that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending. Provider Groups The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services: ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements, Networks of individual practices of ACO professionals, Partnerships or joint ventures arrangements between hospitals and ACO professionals, or Hospitals employing ACO professionals. Other Medicare providers and suppliers as determined by the Secretary The Secretary has determined that Critical Access Hospitals (CAH) billing under Method II would be included in the proposed groups of providers. In the final rule, CMS is adding Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) Legal Structure CMS is finalizing the proposal for an ACO's legal structure must provide both the basis for its shared governance as well as the mechanism for it to receive and distribute shared savings payments to ACO participants and providers/suppliers CMS is requiring an ACO to be an organization that is recognized and authorized to conduct its business under applicable State law and is capable of:

2 Receiving and distributing shared savings; Repaying shared losses; Establishing, reporting, and ensuring ACO participant and ACO provider/supplier compliance with program requirements, including the quality performance standards; and Performing the other ACO functions identified in the statute. An ACO formed among multiple ACO participants must provide evidence in its application that it is a legal entity separate from any of its ACO participants. Distribution of Savings CMS is finalizing the proposal to make any shared savings payments directly to the ACO as identified by its Tax Identification Number (TIN). Governance CMS is finalizing that an ACO must maintain an identifiable governing body with authority to execute the functions of the ACO as defined in this final rule, including but not limited to, the definition of processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinating care. The governing body must have responsibility for oversight and strategic direction of the ACO, holding ACO management accountable for the ACO's activities. Composition of the Governing Body CMS is finalizing the proposal that in order to be eligible for participation in the Shared Savings Program, the ACO participants must have at least 75 % control of the ACO's governing body. The governing body of the ACO must be separate and unique to the ACO in the cases where the ACO comprises multiple, otherwise independent entities that are not under common control. However, the members of the governing body may serve in a similar or complementary manner for a participant in the ACO. In cases in which the composition of an ACO s governing body does not meet the 75% ACO participant control threshold or include the required beneficiary governing body representation, the ACO must describe why it seeks to differ from the established requirements Leadership and Management Structure CMS finalizes that ACO s meet the following criteria: The ACO's operations would be managed by an executive, officer, manager, or general partner, whose appointment and removal are under control of the organization's governing body and whose leadership team has demonstrated the ability to influence or direct clinical practice to improve efficiency processes and outcomes Clinical management and oversight must be managed by a senior-level medical director who is one of the ACO's physicians, who is physically present on a regular basis in an established ACO location, and who is a board-certified physician and licensed in one of the States in which the ACO operates ACO participants and ACO providers/suppliers would have a meaningful commitment to the ACO's clinical integration to the mission of the ACO Required Reporting on Participating ACO Professionals CMS is finalizing the proposal that entities applying to participate in the Shared Savings Program must provide not only the TINs of the ACO and the ACO participants, but also a list of national provider identifiers (NPIs) associated with the ACO providers/suppliers, which would separately identifies the physicians that provide primary care. CMS is requiring that in order to be eligible to participate in the Shared Savings Program, the ACO provide documentation in its application describing its plans to: Promote evidence-based medicine; Promote beneficiary engagement; Report internally on quality and cost metrics; and Page 2

3 Page 3 Coordinate care Start Date Program to be established by January 1, First round of applications are due In early 2012 First ACO agreements start on 4/1/2012 and 7/1/2012 ACO s will have agreements with a first performance year of 18 to 21 months ACO s starting on 4/1/2012 and 7/1/2012 have the option for an interim payment if they report CY2012 quality measures. ACO s must report quality measures for CY2013 to qualify for first performance year shared savings Timing and Process for Evaluating Shared Savings CMS will use 3-month claims run-out to calculate the benchmark and per capita expenditures for the performance year. The proposed 6-month claims run-out was reduced to 3-months as a result of the review of the many public comments on this issue. Assignment CMS will implement a step-wise approach to beneficiaries: Step 1 for beneficiaries who have received at least one primary care service from a physician, use of plurality of allowed charges for primary care services rendered by primary care physicians Step 2 for beneficiaries who have not received any primary care services from a primary care physician, use of plurality of allowed charges for primary care services rendered by any other ACO professional Prospective vs. Retrospective Beneficiary Assignment to Calculate Eligibility for Shared Savings Assignment will be updated quarterly based on the most recent 12 months of data. Final assignment is determined after the end of each performance year based on data from that year. Beneficiary assignment to an ACO is for purposes of determining the population of Medicare FFS beneficiaries for whose care the ACO is accountable, and for determining whether an ACO has achieved savings. Determine assignment to an ACO under the Shared Savings Program based on a statistical determination of a beneficiary's utilization of primary care services. Payment for Services Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems. CMS will also develop a benchmark for each ACO against which ACO performance is measured to assess whether it qualifies to receive shared savings, or for ACO s that have elected to accept responsibility for losses, potentially be held accountable for losses. The benchmark is an estimate of what the total Medicare fee-for-service Parts A and B expenditures for ACO beneficiaries would otherwise have been in the absence of the ACO, even if all of those services were not provided by providers in the ACO. This benchmark will be updated for each performance year within the agreement period. Quality Measures The final rule includes 33 quality measures, down from the proposed 65 quality measures. Electronic Health Records (EHR) no longer a condition of participation, but weighted higher for performance scoring. ACOs must meet a certain quality performance standard.

4 Total Points for Each Domain within the Quality Performance Standard Domain Total Individual Measures Total Measures for Scoring Purposes Total Potential Points Per Domain Domain Weight Patient/Caregiver 7 1 measure with 6 survey module measures 4 25% Experience combined, plus 1 individual measure Care Coordination/ 6 6 measures, plus the EHR measure doubleweighted 14 25% Patient Safety (4 points) Preventative 8 8 measures 16 25% Health At Risk Population 12 7 measures, including 5 component diabetes 14 25% composite measure and 2 component CAD composite measure Total % Performance Scoring Quality Points ACO Performance Level except EHR EHR Points 90+ percentile FFS/MA Rate or 90+ percent 2.00 points 4.0 points 80+ percentile FFS/MA Rate or 80+ percent 1.85 points 3.7 points 70+ percentile FFS/MA Rate or 70+ percent 1.70 points 3.4 points 60+ percentile FFS/MA Rate or 60+ percent 1.55 points 3.1 points 50+ percentile FFS/MA Rate or 50+ percent 1.40 points 2.8 points 40+ percentile FFS/MA Rate or 40+ percent 1.25 points 2.5 points 30+ percentile FFS/MA Rate or 30+ percent 1.10 point 2.2 points <30 percentile FFS/MA Rate or <30 percent No points No points Payment Models CMS is implementing both a one-sided model (sharing savings, but not losses, for the entire term of the first agreement) and a two-sided model (sharing both savings and losses for the entire term of the agreement), allowing the ACO to opt for one or the other model for their first agreement period. CMS will also establish a minimum savings rate (MSR) and a minimum loss rate (MLR) to account for normal variations in health care spending. The MSR is a percentage of the benchmark that ACO expenditure savings must meet or exceed in order for an ACO to qualify for shared savings in any given year. Similarly, an ACO with expenditures at or above the MLR will be accountable for repaying shared losses. Under the final rule, ACOs in the one-sided model that have smaller populations (and having more variation in expenditures) will have a larger MSR and ACOs with larger populations (and having less variation in expenditures) have a smaller MSR. Under the two-sided model, CMS will apply a flat 2% MSR to all ACOs. Shared Savings Under both models, if an ACO meets quality standards and achieves savings and also meets or exceeds the minimum savings rate, the ACO will share in savings, based on the quality score of the ACO. ACOs will share in all savings, not just the amount of savings that exceeds the minimum savings rate, up to a performance payment limit. Similarly, ACOs with expenditures meeting or exceeding the minimum loss rate will share in all losses, up to a loss sharing limit. Page 4

5 Page 5 Shared Savings Program Overview Issue One-Sided Model Two-Sided Model Transition to Two-Sided Model Benchmark Payments outside Part A and B claims excluded from benchmark and performance year expenditures Maximum Sharing Rate Quality Sharing Rate Participation Incentives Minimum Savings Rate Minimum Loss Rate Performance Payment Limit Performance payment withhold First agreement period under one-sided model. Subsequent agreement periods under two-sided Model Option 1 reset at the start of each agreement period. Exclude GME, PQRS, erx, and EHR incentive payments for eligible professionals, and EHR incentive payments for hospitals Up to 50% based on the maximum quality score Up to 50% based on quality performance No additional incentives Not Applicable Option 1 reset at the start of each agreement period Exclude GME, PQRS, erx, and EHR incentive payments for eligible professionals, and EHR incentive payments for hospitals Up to 60% based on the maximum quality score Up to 60% based on quality performance No additional incentives 2.0% to 3.9% depending on number of assigned Finalizing proposal: Flat 2% beneficiaries Shared losses removed from 2.0% Track 1 10% 15% No withhold No withhold Shared Savings First dollar sharing once MSR is met or exceeded. First dollar sharing once MSR is met or exceeded. Shared Loss Rate Shared losses removed from Track 1 Loss Sharing Limit Source: CMS Shared losses removed from Track 1. One minus final sharing rate applied to first dollar losses once minimum loss rate is met or exceeded; shared loss rate not to exceed 60% Limit on the amount of losses to be shared phased in over 3 years starting at 5% in year 1; 7.5% in year 2; and 10% in year 3. Losses in excess of the annual limit would not be shared

6 Page 6 Estimated Net Federal Savings, Costs and Benefits CY CY2015 Federal Savings (in millions) CY2012 CY2013 CY2014 CY2015 Total 10th Percentile $ (30) $ (20) $ 10 $ - $ (40) Median $ 20 $ 90 $ 160 $ 190 $ th Percentile $ 70 $ 210 $ 320 $ 370 $ 970 ACO Bonus Payments 10th Percentile $ 60 $ 180 $ 280 $ 360 $ 890 Median $ 100 $ 280 $ 410 $ 520 $ 1,310 90th Percentile $ 170 $ 420 $ 600 $ 740 $ 1,900 Costs The estimated start-up investment costs for participating ACOs range from $29 million to $157 million, with annual ongoing costs ranging from $63 million to $342 million, for the anticipated range of 50 to 270 participating ACOs. With the mean participation of ACOs, the estimated aggregate average start-up investment and four year operating costs is $451 million Source: CMS CIT Outlook The CMS final Medicare Accountable Care Organization regulations incorporate several significant changes made by CMS from the proposed regulations including: Shared dollar savings for both models once MSR has been achieved Flexible starting date in program established by 1/1/2012 with ACO agreements starting 4/1/2012 through 7/1/2012 Track One - Maximum Savings Rate up to 50% - Track Two 60% EHR is no longer a condition of participation Quality measures reduced to 33 measures in 4 domains proposal was 65 quality measures Advanced Payment model to assist in up-front costs, recoupment options vary based on payment choices, ACO population We believe CMS incorporated the above key changes as a result of receiving over 1,300 public comments and several prominent health systems declining to participate in the ACO program based on the proposed regulations. At this time, it is unclear if the final regulations will be enough for entities to apply to participate; however, many of the relaxed changes were based on the recommendations of the public comments.

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