1 Medicare Shared Savings Program & Accountable Care Organizations American Osteopathic Association National Member Webinar January 5, 2012
2 Overview AOA Position on Practice Transformation and Integrated Health Systems Medicare Shared Savings Program Legislative & Regulatory History Medicare Shared Savings Program (MPPS) Final Rule
3 AOA Policy on Integrated Delivery Models The AOA supports the establishment of new integrated delivery models like accountable care organizations (ACO) that will achieve the triple aim of better care for individuals, better health for populations, and lower per capita spending for Medicare beneficiaries. We are especially supportive of new delivery models that enhance and promote the role of primary care physicians as the foundation for the health care system and place emphasis on the promotion of coordinated care across the health care spectrum.
4 LEGISLATIVE & REGULATORY HISTORY
5 Legislative History The Medicare Shared Savings Program was established by Section 3022 of the Affordable Care Act (P.L ). The Medicare Shared Savings Program must begin by January 1, The Patient Protection and Affordable Care Act was enacted into law on March 23, 2010.
6 Regulatory History The Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking (NPRM) on March 31, Comments were due June 6, 2011 The final rule was published on October 20, 2011 The Department of Justice (DOJ), the Federal Trade Commission (FTC), and the Internal Revenue Service (IRS) have issued final rules respectively on the antitrust, fraud and tax provisions.
7 Regulatory History HHS released 3 additional ACO programs through the Center for Medicare and Medicaid Innovation (CMMI) on May Pioneer Model 2. Advanced Payment Model 3. Accelerated Learning Programs
8 Disclaimer This presentation only contains information on the major changes made to the proposed rule which was released on March 31, 2011 and finalized on October 20, You can access information on the proposed and final rules at
9 MAJOR CHANGES IN THE FINAL RULE
10 Governance ACO participants control 75% of governing body ACO must have senior-level physician medical director
11 Assignment of Beneficiaries Final rule uses a hybrid of prospective assignment with retrospective assignments ACO will receive list of patients likely to be assigned prior to year 1 based upon criteria outlined in proposed rule. Specialist visits for primary care services will count towards assignment if no primary care physician services are available.
12 Risk Models Track 1 ACOs can earn shared savings independent of penalties for spending above their benchmark. First dollar shared savings once minimum threshold is reached
13 Alternative Shared Savings Programs Center for Medicare and Medicaid Innovation will offer alternative shared savings program Bundled payment initiative Comprehensive primary care initiative Innovation grants Advanced payment ACOs
14 Quality Reporting Quality measures reduced from 65 to 33 Requirement that 50% of primary care physicians be meaningful users of electronic health records removed Hospital acquired condition (HAC) measures removed
15 FTC, DOJ, CMS, OIG No mandatory antitrust review Expedited 90-day voluntary review Self-referral and gainsharing waivers Waiver for care coordination and beneficiary inducement programs
16 MEDICARE SHARED SAVINGS PROGRAM
17 Accountable Care Organizations (ACO) An Accountable Care Organization (ACO) encourages providers of services and suppliers 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.
18 Triple Aim Goals of the Shared Savings Better care for individuals Program Better health outcomes for populations Lower per capita cost Promote accountability for a population of Medicare beneficiaries Improve the coordination of Medicare Fee-For-Service items and services Improve care transitions between providers and services Encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery Incent higher value care
19 DEFINITIONS & GOALS
20 Definition An Accountable Care Organization (ACO) encourages providers of services and suppliers 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.
21 Who Can Be an ACO Eligible Entities ACO professionals in group practice arrangements Networks of individual practices of ACO professionals Partnerships or joint venture arrangements between hospitals and ACO professionals Hospitals employing ACO professionals Such other groups or providers of services and suppliers as the Secretary determines appropriate Critical Access Hospitals (CAHs) Must bill under Method II payment model Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) employing ACO professionals
22 What is an ACO Professional? An ACO professional is a physician, which refers to a doctor of medicine or osteopathy, or a practitioner, which includes physician assistants, nurse practitioners, or clinical nurse specialists. The term hospital means a hospital paid under the hospital inpatient prospective payment system (PPS).
23 BENEFICIARY ASSIGNMENT & DATA SHARING
24 Beneficiary Assignment Beneficiaries retain freedom of health care choices. Beneficiaries are assigned prospectively based on plurality of primary care services during prior 3-year period. Only DO/MD services NP, PA data is applicable for beneficiary assignment, but cannot be sole criteria Services provided by specialists are eligible for beneficiary attribution if there is an absence of primary care services Beneficiaries are aligned with only one ACO at a time. Beneficiaries may opt-out of ACO data sharing, but beneficiary data still counts towards benchmark and risk.
25 Definition of Primary Care Services Beneficiaries are assigned based on care provided by primary care physicians (internal medicine, general practice, family practice, and geriatric medicine) who are providing the defined primary care services. Codes include: , , , G0438, G0439 and G0402. Other prevention and immunization codes also included. Services provided by nurse practitioners and physician assistants will count towards the assignment of beneficiaries, but cannot be the sole criteria.
26 Challenges Methodology for Attributing Patients to ACOs The ACO will not know for sure which patients they will get savings credit for until after the year is over A patient is attributed for a full year, so costs incurred before new patients started using the ACO s doctors will be attributed to the ACO As a result, ACOs with stable patient populations are more likely to get credit for savings they achieve, and avoid penalties for prior costs Methodology for Projecting Increase in Cost Per Patient CMS will assume costs per patient will increase by the absolute amount of increase nationally (not the percentage growth) This means it will be harder for high-cost regions to achieve minimum savings Risk Adjustment in Projecting Future Costs CMS will make adjustments for the relative health status of new patients so that ACOs are not penalized for getting new, sicker patients CMS will not make adjustments to cost projections if existing patients get sicker, so the ACO will be penalized if existing patients get sicker CMS will make adjustments to cost projections if existing patients get healthier, which means the ACO won t get credit for savings from improving the health of its existing patients
27 Data Sharing Aggregate CMS will share with ACO aggregate data at the start of the 3- year agreement Data covers beneficiaries who may be assigned based on previous 12 months data No beneficiary consent required Four Primary Data Sets Name, date of birth, gender, HICN of historically assigned beneficiaries CMS will share at the beginning of the agreement period No beneficiary consent required Beneficiary Identifiable Data CMS will share on request Data limited to beneficiaries who saw participating ACO professional in previous 12 months Beneficiary may optout of data sharing
28 QUALITY IMPROVEMENT CRITERIA
29 1. Ongoing patient experience evaluation 2. Patient involvement with governance 3. Evaluating population needs and diversity 4. Identifying high risk individuals Use of individualized care plans Use of community resources Patient Centeredness 5. Coordination of care Use of EHRs and exchange of e-information between sites of care 6. Communicating clinical knowledge Use of shared decision making 7. Beneficiary access to medical records Written standards that describe related policies and procedures 8. Internal Process to measure clinical service by physicians as part of the quality assurance program requirements
30 Quality Improvement CMS proposes 33 measures in 4 quality domains. Use same weight for all quality domains To meet quality performance standards an ACO must: Report on quality measures Meet applicable performance criteria Year 1 ACOs are only required to report quality date with performance evaluation in years 2 and 3 Higher standards and additional measures over time Quality benchmarks based on Medicare fee-for-service and Medicare Advantage or ACO performance data. ACOs that don t meet the quality performance thresholds for all proposed measures will not be eligible for shared savings.
31 Quality Measures Quality Domain ACO Quality Measures Reports Results Patient/Caregiver Experience Care Coordination/ Patient Safety Preventive Health At Risk Population Source American Medical Association CAHPS Measures (1 6-part composite) CAHPS Health/Functional Status Risk-Adjusted All-Cause Readmissions Ambulatory Care Sensitive Admits (2) PCPs Using EHRs (double-weighted) Medication Reconciliation Screening for Fall Risk Immunizations (2) Weight Screening Tobacco Use/Cessation Depression Screening Cancer Screening (2) Blood Pressure Screening Diabetes Control (1 5-part composite) Diabetes Hemoglobin Control Hypertension Control Ischemic Vascular Disease (2) Heart Failure Coronary Artery Disease Composite (2) Year 1 Years 1-3 Years 1-2 Year 1 Year 1 Year 1 Year 1 Year 1 Year 1 Year 1 Year 1 Years 1-2 Years 1-2 Year 1 Year 1 Year 1 Year 1 Years 1-2 Years 1-2 Years 2-3 None Year 3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Year 3 Year 3 Years 2-3 Years 2-3 Years 2-3 Years 2-3 Year 3 Year 3
32 Shared Savings Depends on Quality Step 1: Step 2: Step 3: Step 4: Score each individual measure compared to national or absolute benchmarks (0 if below 30%) Combine scores for each measure into a score for each of the 4 domains Combine scores for each domain into a total score between 0% and 100% Determine actual share of savings by multiplying % score by maximum % savings Performance on Measure Score % 100.0% 80-89% 92.5% 70-79% 85.0% 60-69% 77.5% 50-59% 70.0% 40-49% 62.5% 30-39% 55.0% 0-29% 0.0% Weight for Measure Weight for Domain Domain Patient/Caregiver Experience 50.0% 25% Care Coordination/Patient Safety 14.3% 25% Preventive Health 12.5% 25% At Risk Population 14.3% 25% Source American Medical Association
33 SHARED SAVINGS
34 Two Risk Models One-Sided Risk Model Two-Sided Risk Model
35 How Shared Savings Works Healthcare Spending Source American Medical Association
36 Step 1: Current Spending Levels for ACO Patients Healthcare Spending Baseline Spending Source American Medical Association
37 Step 2: Future Spending Projected Based on National Trends Healthcare Spending Projected Spending Baseline Spending Source American Medical Association
38 Step 3: Medicare Totals What Was Actually Spent on the Patients Healthcare Spending Baseline Spending Projected Spending Actual Spending Note that total spending can still be higher than the prior year, it just needs to be lower than what is projected Source American Medical Association
39 Step 4: If Savings Exist, Medicare Shares With the ACO Healthcare Spending Baseline Spending Projected Spending Actual Spending Initial Portion of Savings Accrues to Medicare Share of Savings Returned to ACO Source American Medical Association
40 Shared Savings Increase If Costs Remain Low Healthcare Spending Baseline Spending Medicare Share ACO Share Projected Spending Actual Spending Medicare Share of Savings ACO Share of Savings Source American Medical Association
41 What Happens if Costs Increase Above Expected Growth Rate? Actual Spending Healthcare Spending Projected Spending Baseline Spending Source American Medical Association
42 Track 1 No Penalty Healthcare Spending Actual Spending Projected Spending Medicare Covers The Increased Cost Baseline Spending Source American Medical Association
43 Track 2 ACO Shares In Losses Healthcare Spending Actual Spending Projected Spending ACO Repays Medicare Medicare Covers Small Increases in Cost Baseline Spending Source American Medical Association
44 What Happens After the Initial 3 Year ACO Contract? Healthcare Spending Baseline Spending Projected Spending Actual Spending Medicare Share ACO Share Source American Medical Association
45 Initial Savings Will Be Assumed As the New Baseline Healthcare Spending Projected Spending Based on New Baseline Baseline Spending Actual Spending Source American Medical Association
46 ACO Receives Bonuses/Penalties Based on Costs vs. New Baseline Healthcare Spending Baseline Spending Actual Spending ACO Pays Medicare No Bonus or Penalty Medicare Pays ACO Source American Medical Association
47 Foundation for Shared Savings An ACO shall be eligible for payment of shared savings only if the estimated average per capita Medicare expenditures under the ACO for Medicare FFS beneficiaries for Parts A and B services, adjusted for beneficiary characteristics, are at least the percent specified below the benchmark. The rule proposes a percentage that expenditures must be below the benchmark this percentage is called the minimum savings rate or MSR. A benchmark must be established and updated for each agreement period If an ACO meets the quality performance standards, a percentage of the differences between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under the ACO and such benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the Medicare program. This is called the sharing rate. The rule establishes limits on the total amount of shared savings that may be paid to an ACO. This is called the sharing cap.
48 Shared Savings Methodology Establish a Benchmark Compare benchmark versus actual costs Compare savings/loss to minimum savings rate If MSR is met, determine the sharing rate based on quality performance scores Apply sharing cap to savings/losses
49 Establishing an Expenditure Benchmark The benchmark is a surrogate measure of what the Medicare FFS Parts A and B expenditures would otherwise have been in the absence of the ACO. CMS proposes to estimate an ACOs benchmark based on Parts A and B expenditures of beneficiaries who would have been assigned to the ACO in each of the 3 years prior to the start of an ACOs agreement period using the ACO participants TINs. CMS would use the claim records of ACO participants to determine a list of beneficiaries who received a plurality of their primary care services from primary care physicians participating in the ACO in each of the prior 3 most recent available years.
50 Establishing an Expenditure Benchmark (cont.) Using the per capita Parts A and B Medicare FFS expenditures for beneficiaries that would have been assigned to the ACO in each of these 3 prior years, CMS will estimate a fixed benchmark that is adjusted for overall growth and beneficiary characteristics, including health status using prospective HCC adjustments. The benchmark would be updated annually during the agreement period based on the absolute growth in national per capita expenditures for Parts A and B services under the original Medicare FFS program.
51 Benchmark Methodology Determine patient population assigned to the ACO Based on plurality of services received from primary care providers participating in the ACO Determine Medicare Part A & B expenditures over prior 3 year period for assigned population that would have been assigned to the ACO Make benchmark adjustments for beneficiary characteristics Demographic factors Diagnosis factors Make adjustments to benchmark DSH and IME payments Geographic factors high cost/low cost region Apply trend factor to benchmark Benchmark calculation date to agreement start date Annual adjustment based on national per capita growth
52 Shared Savings Criteria Minimum Sharing Rate The percentage that expenditures must be below the benchmark to account for normal variation, based upon the number of Medicare FFS beneficiaries assigned to an ACO. Sharing Rate A percentage of the differences between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, the benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the Medicare program. Sharing Cap The limits on the total amount of shared savings that may be paid to an ACO. Shared Losses The amount of costs that exceed an ACOs benchmark. Only applies to 2- sided model.
53 Shared Savings Criteria (cont.) ACO Risk Model Medical Savings Rate 2-Sided Model Flat 2% 1-Sided Model Tiered from 3.9% to 2% Beneficiaries Confidence Interval MSR 5,000 90% 3.9% to 3.6% 6, % to 3.4% 7, % to 3.2% 8, % to 3.1% 9, % to 3% 10,000 3% to 2.7% 15, % to 2.5% 20,000 95% 2.5% to 2.2% 50,000 99% 2.2% to 2% 60,000 2%
54 Track 1 vs Track 2 Track 1: Smaller Share of Savings Minimum savings rate of up to 3.9% for small ACOs Medicare pays ACO up to 50% of savings Savings shared only up to 10% of total costs ACO pays 0% of any cost increases Track 2: Larger Share Savings & Cost Minimum savings rate of 2% for large and small ACOs Medicare pays ACO up to 60% of savings Savings shared up to 15% of total costs ACO pays Medicare up to 60% of cost increases if costs increase more than minimum threshold, but no more than 5-10% of costs
55 WHAT S IN IT FOR PHYSICIANS?
56 $600,000 Majority of Medicare Spending Doesn t Go To Physicians Medicare Expenditures (Millions), 2009 $500,000 $400,000 Administration Other Nursing Care Home Health Prescriptions $300,000 $200,000 Hospitals (41%) $100,000 $0 Physician/ Clinical (21%) Source American Medical Association
57 But Physicians Influence a Majority of Medicare Spending $600,000 Medicare Expenditures (Millions), 2009 $500,000 $400,000 $300,000 $200,000 Administration Other Nursing Care Home Health Prescriptions Hospitals (41%) Physicians Prescribe, Control, or Can Potentially Influence $100,000 $0 Source American Medical Association Physician/ Clinical (21%)
58 Shared Savings Lets Physicians Gain From Reduced Spending $600,000 $500,000 $400,000 $300,000 $200,000 Administration Other Nursing Care Home Health Prescriptions Hospitals (41%) CMS Savings Administration Other Nursing Care Home Health Prescriptions Hospitals $100,000 $0 Source American Medical Association Physician/ Clinical (21%) More $ for Physicians
59 Keys to Shared Savings Total costs for ALL services and procedures to the attributed patients must be lower than projected Total costs don t have to be lower than previous year, however, they have to be lower than CMS projects they would have been for current year Even if savings are achieved for some patients or procedures, if costs increase elsewhere, there may be no net savings to share Savings must be greater than the minimum set by CMS Savings are only attributed to the ACO if the patient received the plurality of their primary care through ACO The shared savings payment comes to the ACO; not all of it may be allocated to physicians, or to the subset of physicians responsible for generating it
61 What the Goal Looks Like for 5,000 Patients (~10 PCPs) Current and Projected Spending Year 0 Projected Year 1 Beneficiaries 5,000 5,000 Total Per Beneficiary $10,000 $10,300 Total Medicare Part A & B Spending $50,000,000 $51,500,000 Shared Savings Calculation Minimum Savings Rate 3.9% Minimum Savings Needed $2,008,500 Potential Shared Savings Bonus (50%) Source American Medical Association
62 Large Potential Bonus in Years 2+ If Minimum Savings Achieved Current and Projected Spending Year 0 Projected Year 1 Projected Year 2 Projected Year 3 Beneficiaries 5,000 5,000 5,000 5,000 Total Per Beneficiary $10,000 $10,300 $10,600 $10,900 Total Medicare Part A & B Spending $50,000,000 $51,500,000 $53,000,000 $54,500,000 Shared Savings Calculation Minimum Savings Rate 3.9% 3.9% 3.9% Minimum Savings Needed $2,008,500 $2,067,000 $2,125,500 Potential Shared Savings Bonus (50%) $1,004,250 $1,033,500 Source American Medical Association
63 Physicians Only Different ACO Arrangements, Different Challenges No need to share savings with hospital, but reduced ability to manage hospital-driven costs Physicians & Hospitals Better ability to manage hospital-driven costs, but savings need to be shared with hospital, and hospital could demand most of the savings since most savings will come from reduced hospital revenues
64 Shared Savings Provides No Upfront Financing for Physicians Shared Savings makes no changes in the underlying payment system, so a physician practice or hospital that does fewer billable activities and shifts resources to non-billable activities (e.g., phone calls, hiring nurse care managers to work with chronic disease patients, etc.) will lose money in the short run, and possibly in the long run Shared Savings are not paid until the year after savings are achieved, so even if savings ultimately offset initial losses or costs, there could be cash flow problems Hospitals or health plans have been viewed as essential to ACO formation because most physician groups and IPAs do not have capital reserves to cover short term losses or finance improved infrastructure
65 Advance Payment Program CMS Innovation Center is committing up to $170 million for up to 50 ACOs to help cover upfront costs Only open to two types of ACOs: ACOs that do NOT include inpatient facilities and have less than $50 million in total annual revenue ACOs whose ONLY inpatient facilities are Critical Access Hospitals or lowvolume Rural Hospitals and have <$80 million in total revenue Three-part financial assistance: Upfront fixed payment of $250,000 $36 per assigned beneficiary in the first month $8 per beneficiary per month over two years Assistance is a forgivable loan, not a grant The upfront assistance is deducted from any shared savings bonuses If shared savings is less than advance payment, the balance is forgiven Total for smallest ACO (5,000 members): $1.5 million ($430,000 upfront + $1.1 million over 23 months)
66 Does the Shared Savings Program Force Hospitals To Hire Physicians? Hospitals are not directly eligible for shared savings; savings are only attributed to the ACO if it includes the primary care physicians or specialists who are providing the plurality of primary care services to the patients Even if the hospital reduces readmissions, infections, complications, etc., it would receive no share of savings unless the patients received primary care from the ACO Reducing hospitalizations, ER visits, etc. will reduce the hospital s revenues, but the hospital may receive no share of the savings to help it cover its stranded fixed costs Consequently, hospitals may feel compelled to own physician practices, either to capture a portion of the shared savings revenue, or to prevent there from being any savings!
67 Challenges For Physicians 1. Choosing partners to form the ACO 2. Getting and analyzing utilization and quality data 3. Reinventing care to improve quality and reduce costs 4. Getting commercial payers to provide support 5. Patient compliance
68 Selecting Partners Physicians will need to identify other physicians and potentially hospitals to explore partnerships Physicians will want to know quality/performance of other physicians and hospitals before forming partnerships Including poor quality providers will hurt the ACO s ability to capture shared savings even if costs are reduced ACOs may not just want the best providers as partners; there are opportunities for high-performing providers to partner with low-performing providers, where the high-performer shares expertise, and the lowperformer s improvement generates savings for both
69 Data A major barrier to formation of ACOs is lack of data to understand the total utilization pattern of potentially assigned Medicare beneficiaries: where the savings opportunities are, where the risks of cost increases are CMS will provide data to ACOs, but only after they begin operations Even when they get claims data from Medicare, ACO physicians and hospitals may need technical assistance analyzing claims and their own clinical data to help determine where opportunities are for improvement It s easier to identify opportunities for improvement when you have something to compare to, so community and national analyses of performance of other providers will help
70 Care Improvements Reinventing care processes to improve quality and reduce costs Physician practices will need time and skills to analyze and redesign care processes Improving patient experience will be a much more important factor than ever before, since Patient and Caregiver Experience will be 25% of performance score
71 Support From Commercial Insurers Physicians need all or most payers to support major practice changes, not just Medicare Some states and non-profit Regional Health Improvement Collaboratives are encouraging/facilitating commercial and Medicaid payers to participate in multi-payer payment reforms
72 Patient Compliance Medicare is not giving patients any incentives to cooperate with the ACO s efforts to improve quality and reduce costs; indeed, it will be reminding patients of their right to choice Medicare will be reviewing/restricting the ability of an ACO to market the value of its coordinated services to patients Patient adherence to care plans can be critical to improved outcomes Community organizations could help by educating patients about the value of medical homes, coordinated team care, choosing high-value providers, adhering to care plans, etc.
73 Should You Participate and/or Form an ACO? YES Opportunity to get bonuses for reducing utilization, with no risk of penalty if costs go up (under Track 1 model) Small physician groups can form an ACO while remaining independent through Independent Practice Association and Physician- Hospital Organizations Upfront payment available for physician-led ACOs from Advance Payment Initiative NO Doesn t change the underlying payment system Bonuses only provided if significant savings and quality achieved Patients will be assigned retrospectively based on statistical utilization, not based on patient choice Providers have no control over where patients get care Savings only shared for 3 years, then starting point is reset to zero
74 PARTICIPATION IN AN ACO
75 Participation in an ACO Minimum Requirements Legal entity recognized under relevant state laws Tax identification number The legal entity may or may not be an enrolled Medicare provider and/or supplier Capable of ensuring compliance with ACO laws and rule, quality improvement requirements, and data reporting Capable of receiving and distributing savings Capable of performing all functions outlined in law and rules
76 Participation in an ACO Legal Structure and Governance 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 saving payments to ACO participants and providers/suppliers. Legal Entity Governance Governing Body
77 Legal Entity ACO must be constituted as a legal entity appropriately recognized and authorized to conduct its business under applicable State and it must have a tax identification number (TIN). The ACO is not required to be enrolled in the Medicare program, but all participants must have a NPI. A recognized ACO must be capable of: 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 statute
78 Legal Entity (cont.) Existing legal entities appropriately recognized under State law are not required to form a separate new entity for the purpose of participation in the Shared Saving Program if the existing legal entity meets the eligibility requirements to be an ACO. If an existing entity wishes to include other providers/suppliers who are not already part of its existing legal structure, a separate legal entity would have to be established. An ACO with operations in multiple States would have to certify that it is recognized as a legal entity in the State in which it was established and that it is authorized to conduct business in each State in which it operates.
79 Governance Governance should allow for appropriate proportionate control for ACO participants. The governing body must be capable of defining the processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care. The governing body would be comprised of: ACO participants Medicare beneficiaries Professionals who accept responsibility for the ACOs administrative, fiduciary, and clinical operations. If the ACO is comprised of a self-contained financial and clinically integrated entity that has a pre-existing board of directors or other governing body, they are not required to form a separate governing body as long as the governing body is able to meet all other criteria required for ACO governing bodies.
80 Composition of Governing Board The ACO should be operated and directed by Medicare-enrolled entities that directly provide health care to beneficiaries. ACO participants (physicians) must have at least 75 percent control of the ACOs governing body. Each ACO participant must choose an appropriate representative from within its organization to represent them on the governing body. The ACO must integrate community resources as an essential part of patient centeredness.
81 Leadership and Management Structure The ACO must have in place a leadership and management structure that includes clinical and administrative systems. Dedicated physician leadership Clinical management and oversight managed by a senior-level medical director who is a board-certified physician, licensed in the State in which the ACO operates, and is physically present in that State. ACO must have a physician-directed quality assurance and process improvement committee that would oversee an ongoing quality assurance and improvement program. 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
82 Leadership and Management Structure (cont.) Health information technology that facilitates the aggregation and analysis of data, allows patient-level feedback, and provides alerts and reminders at the point of care Experience with non-medicare payer initiatives ACO must develop and implement evidence-based medical practice or clinical guidelines ACO would have an infrastructure, such as information technology, that enables the ACO to collect and evaluate data and provide feedback to the ACO providers/suppliers across the entire organization, including providing information to influence care at the point of care via shared clinical decision support, feedback from patient experience of care surveys or other internal or external quality and utilization assessments.
83 Participation in an ACO Agreement Requirements Participation agreements are limited to three years. The ACO acknowledges that it will comply with all the requirements for participation in the Shared Savings program and that all related contracts and arrangements must require compliance with the ACO obligations under the three-year agreement. If an ACO needs to discontinue its participation in the Shared Savings Program prior to the end of the three- year agreement period, the ACO must give CMS 60-days advance written notice and the date of termination. ACOs will be subject to a 25 percent withholding to offset any future losses. If the ACO successfully completes its three-year agreement, CMS will refund, in full, any portion of shared savings withheld that is not needed to offset losses. If the agreement is terminated before completion of the three years, CMS will retain any portion of shared savings withheld. All ACOs, ACO participants, and ACO providers/suppliers with direct or indirect obligations under the program be subject to the requirements of the agreement between the ACO and CMS.
84 Participation in an ACO Number of Beneficiaries ACOs participating in the Medicare Shared Savings program must have at least 5,000 assigned beneficiaries. If the ACO s assigned beneficiary population falls below 5,000 during the course of the agreement period, (3 years) CMS would issue a warning and place the ACO on a corrective action plan. The ACO would still be eligible for shared savings for the performance year for which the warning was issued. The ACO must increase its assigned beneficiary population to 5,000 or greater. If the ACO fails to meet the 5,000 beneficiary threshold by completion of the next performance year, the ACO agreement will be terminated and the ACO will not be eligible to share in savings for that year. CMS reserves the right to review the status of the ACO while on the corrective action plan and terminate the agreement if the ACO no longer meets eligibility requirements.
85 APPLICATION PROCESS
86 Key Dates
87 ACO Application Process First step in applying to be Medicare ACO is submission of a Notice of Intent (NOI): Submitting the NOI web form allows you to get an ACO ID number, which ACOs must have before they can submit an application ACO application information is at: program/37_application.asp
88 ACO Application Process NOI completed by Jan. 6 th for April start NOI must be submitted electronically ACO will get acknowledgment with ACO ID and instructions for completing CMS User ID application Submitting NOI does not require ACO to submit an application for 2012 Without ACO ID and CMS User ID, cannot access Health Plan Management System (HPMS) to complete 2012 application
89 ACO Application Applications must be submitted by Jan. 20 for ACOs to start April 2012 Application package includes: application, electronic funds transfer (form 588), participant list, data use agreement Applications may be submitted via tracked mail or electronically
90 Applying for Advance Payments Participating Advance Payment ACOs will receive three types of payments: An upfront, fixed payment An upfront, variable payment A monthly payment of varying amount depending on the size of the ACO CMS will recoup Advance Payments through an ACO s earned shared savings
91 Applying for Advance Payments Advance Payments only available to ACOs with April or July 2012 start dates For April start date, Advance Payment applications accepted Jan 1 - Feb 1 For July starts, Advance Payment applications accepted Mar 1 - Mar 30 Online application template to be posted: seamless-and-coordinated-care-models/ advancepayment/
92 Resources Centers for Medicare and Medicaid Services American Osteopathic Association Center for Medicare and Medicaid Innovation Medicare Payment Advisory Commission
1 DETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM Definition of ACO General Concept An ACO refers to a group of physician and other healthcare providers and suppliers
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Background Sec. 3022 of the Patient Protection and Affordable Care Act (PPACA) requires the Secretary to establish the Medicare Shared Savings Program by Jan. 1, 2012 Program goals: Promote accountability
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If you proposed an ACO initiative, please fill our this Comparison of Elements for Participation in Medicare Shared Savings Program (MSSP) to State SIM ACO Test Proposal From Funding Opportunity Announcement:
On Oct. 20, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized new rules under the Medicare Shared Savings Program (MSSP) to help doctors, hospitals, and other health care providers better
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Accountable Care Organizations: How Does the DME Join the Party? Presented by: Jeffrey S. Baird, Esq. Chairman, Health Care Group, Brown & Fortunato, P.C. 2015 Brown & Fortunato, P.C. BACKGROUND Accountable
Accountable Care Organization (ACO) 101 Brief Course Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs What is an ACO? ACO refers to a legal entity composed of a group of providers that assume
Gold Coast Health IT Resource Center Accountable Care Organization (ACO) August 27, 2013 Copyright 2013 Gold Coast HIT 1 Agenda Upcoming Webinars ACO s Copyright 2013 Gold Coast HIT 2 Upcoming Webinars
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Accountable Care Organizations: FACT SHEET Overview http://www.cms.gov/sharedsavingsprogram On October 20, 2011, the Centers
Issue Brief 4712 Country Club Drive Jefferson City, MO 65109 P.O. Box 60 Jefferson City, MO 65102 573/893-3700 www.mhanet.com FEDERAL ISSUE BRIEF June 5, 2015 KEY POINTS z More than 400 accountable care
Client Advisory Health Care November 10, 2011 CMS Issues Final ACO Regulations After receiving more than 1,300 public comments on its Proposed Rule for Accountable Care Organizations (ACOs) under the Medicare
Accountable Care Organizations & Other Reimbursement Reforms: The Impact on Physician Practices Martin Bienstock, Esq. Wilson Elser Martin.Bienstock@WilsonElser.com The New York Times Take... For the first
A Closer Look at the Final ACO Rule October 2011 For more information, please contact: On October 20th, the federal government released a final rule and other companion releases relating to Accountable
PROPOSED RULES FOR ACCOUNTABLE CARE ORGANIZATIONS PARTICIPATING IN THE MEDICARE SHARED SAVINGS PROGRAM: WHAT DO THEY SAY? The Affordable Care Act authorizes the Centers for Medicare and Medicaid Services
HEALTH PRACTICE GROUP APRIL 2011 Saul Ewing Health Practice Group: George W. Bodenger Chair What keeps you up at night? The ACO Proposed Rule: A Need to Know Summary By Karen Palestini SUMMARY On March
CMS RELEASES PROPOSED ACCOUNTABLE CARE ORGANIZATION REGULATIONS By: Kathleen L. DeBruhl, Esq. and Lindsey E. Surratt, Esq. On March 31, 2011, the Centers for Medicare and Medicaid Services ( CMS ) issued
Healthcare Committee Medicare Shared Savings Program Final Rule On June 9, 2015, the Centers for Medicare & Medicaid Services ( CMS ) published a final rule that, according to the agency, will update and
HEALTH CARE LAW September 10, 2010 Presented by University of Mississippi Center for Continuing Legal Education Topic: Accountable Care Organizations By Jonell Beeler Baker, Donelson, Bearman, Caldwell
How Will the ACO Regulations Affect You? Wednesday, June 1, 2011 Presented by: Michele Madison Partner, Healthcare & Healthcare IT Practices Ward Bondurant Partner, Healthcare, Insurance & Corporate Practices
Summary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations On November 2, 2011, the Centers for Medicare and Medicaid Services ( CMS ) published a Final Rule implementing the
Physician Care: Understanding the Physician s Role in an Accountable Care Model Presented by Albert R. Riviezzo, Esq. Fox Rothschild LLP Exton, PA Physician's role in an Accountable Care Organization (ACO)
Accountable Care Organizations: Notice of Proposed Rulemaking Presentation by: Pam Silberman, JD, DrPH North Carolina Institute of Medicine April 15, 2011 1 Accountable Care Organizations (ACOs) An ACO
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
Crosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011 The table below details areas where NCQA s ACO Accreditation standards overlap with the CMS Final Rule CMS Pioneer ACO CMS
The Medicare Shared Savings Program Centers for Medicare & Medicaid Services Jonathan Blum, Deputy Administrator & Director, Center for Medicare May 20, 2011 Overview CMS s vision of its ACO program Summary
April 7, 2011 Dear Physician Colleague: On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) issued its long awaited proposed regulations on the Medicare Shared Savings/Accountable Care
Newsroom People with Medicare will be able to benefit from a new program designed to encourage primary care doctors, specialists, hospitals, and other care providers to coordinate their care under a final
December 2010 Using Partial Capitation as an Alternative to Shared Savings to Support Accountable Care Organizations in Medicare CONTENTS Background... 2 Problems with the Shared Savings Model... 2 How
Accountable Care Organization Final Rule Briefing November 7, 2011 Health Care Reform: Health Care Delivery Reforms GOALS: Controlling Cost Growth Improving Quality/Outcomes Changing Incentives Coordinating
Health Law Bulletin provided by: ACOs AND SHARED SAVINGS IN A NUTSHELL Applications to Participate Available Now Earlier this month, the Center for Medicare and Medicaid Services (CMS) published the final
Medicare Shared Savings Program Quality Measure Benchmarks for the 2015 Reporting Year Release Notes/Summary of Changes (February 2015): Issued correction of 2015 benchmarks for ACO-9 and ACO-10 quality
The Accountable Care Organization (ACO) Readiness Application must be submitted and approved by Iowa Medicaid Enterprise (IME) prior to IME processing an ACO Enrollment packet. Readiness Applications must
The Medicare Shared Savings Program and the Accountable Care Organizations Promoting and evaluating accountable care organizations Victoria Boyarsky, FSA, MAAA Rob Parke, FIA, ASA, MAAA Peer reviewed by
Medicare and Commercial Accountable Care Organizations: A Retrospective and Prospective View Troy Barsky, Esq. Jennifer Williams, Esq. Crowell & Moring Daniel Murphy, Esq. Bradley Arant Boult & Cummings
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Improving Quality of Medicare Patients: Overview The Centers for Medicare & Medicaid Services (), an agency within the Department
Physician Integration Models: ACOs as the Latest and Greatest? David T. Lewis email@example.com LifePoint Hospitals, Inc. Brentwood, TN Kim Harvey Looney firstname.lastname@example.org Waller Lansden Dortch
1501 M Street NW Seventh Floor Washington, DC 20005-1700 Tel: 202.466.6550 Fax: 202.785.1756 M E M O R A N D U M To: From: Clients and Friends Powers Pyles Sutter & Verville, PC Date: April 10, 2011 Re:
Finalized Changes to the Medicare Shared Savings Program Background: On June 4, 2015, the Centers for Medicare and Medicaid (CMS) issued a final rule that updates implementing regulations for the Medicare
M A Y 2 0 1 1 Guidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), the Department
Chapter Three Accountable Care Organizations One of the most talked-about changes in health care delivery in recent decades is Accountable Care Organizations, or ACOs. Having gained the attention of both
S T U D E N T E S S A Y Accountable Care Organizations: Principles and Implications for Hospital Administrators Andrew Russell Bennett, James Madison University E X E C U T I V E S U M M A R Y With the
Effective ACO Compliance HCCA Compliance Institute April 21, 2013 Margaret Hambleton, MBA, CHC, CHPC Sr. Vice President, Chief Compliance Officer St. Joseph Health System 1 Objectives Understand Accountable
Mount Sinai Care: A Medicare Shared Savings Program Primer Brett Bernstein, MD, AGAF, FASGE Medical Director, Provider Partners of Mount Sinai IPA Mount Sinai Health System Network Mount Sinai Health System
ANESTHESIA BUSINESS CONSULTANTS SUMMER 2011 VOLUME 16, ISSUE 2 Cms Finally speaks: The accountable Care organization (ACO) proposed regulations and WhaT They mean For anesthesiologists Since the passage
Medicare Shared Savings Program Quality Measure Benchmarks for the 2014 Reporting Year Release Notes/Summary of Changes (February 2015): Issued correction of 2014 benchmarks for ACO-9 and ACO-10 quality
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program Overview The Centers for
701 Pennsylvania Avenue, Ste. 800 Washington, DC 20004 2654 Tel: 202 783 8700 Fax: 202 783 8750 www.advamed.org Meeting of the Advisory Panel on Outreach and Education (APOE) Centers for Medicare and Medicaid
Clinical Quality Reporting: Value Modifier General Internal Medicine Grand Rounds August 13, 2013 Gail Albertson, MD Associate Professor of Medicine Chief Operating Office, University Physicians Future
HEALTH REFORM LAW: ACCOUNTABLE CARE ORGANIZATIONS PRESENTED AT THE NASABA 2011 CONVENTION BY: PURVI B. MANIAR Context and Background Patient Protection and Affordable Care Act of 2010 ( PPACA ) (Section
Fact Sheet AARP Public Policy Institute How Health Reform Will Affect Health Care Quality and the Delivery of Services The recently enacted Affordable Care Act contains provisions to improve health care
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Media Affairs MEDICARE FACT SHEET FOR IMMEDIATE RELEASE
Accountable Care Organization Workgroup Glossary Accountable care organization (ACO) a group of coordinated health care providers that care for all or some of the health care needs of a defined population.
CHAPTER 114 AN ACT establishing a Medicaid Accountable Care Organization Demonstration Project and supplementing Title 30 of the Revised Statutes. BE IT ENACTED by the Senate and General Assembly of the
Fraud and Abuse Considerations for Accountable Care Organizations (ACOs) By: Chris Rossman, Foley & Lardner LLP, Detroit, Michigan 1. The Centers for Medicare and Medicaid Services ( CMS ) and the Office
ACCOUNTABLE CARE ORGANIZATION FINAL REGULATIONS: ANALYSIS AND IMPLICATIONS* Prepared by Hooper, Lundy & Bookman, P.C. November 22, 2011 EDITORS Charles B. Oppenheim Los Angeles Lloyd A. Bookman Los Angeles
Medicare Shared Savings Program: Accountable Care Organizations Centers for Medicare and Medicaid Services Final Rule Provisions The Centers for Medicare and Medicaid Services (CMS) published a final rule
Sustainable Growth Rate (SGR) Repeal and Replace: Comparison of 2014 and 2015 Legislation Proposal 113 th Congress - - H.R.4015/S.2000 114 th Congress - - H.R.1470 SGR Repeal and Annual Updates General
E-ALERT Health Care April 15, 2011 ACCOUNTABLE CARE ORGANIZATION BASICS The Affordable Care Act establishes the Medicare Shared Savings Program ( Program ), which provides for the development of accountable
Incentives to Accelerate EHR Adoption The passage of the American Recovery and Reinvestment Act (ARRA) of 2009 provides incentives for eligible professionals (EPs) to adopt and use electronic health records
Physician Value-Based Payment Modifier How will the VBM Impact Your Practice? What is the Value-Based Payment Modifier (VBM)? The VBM provides for differential payment to a physician or group of physicians
Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation Next Generation ACO Model Request for Applications Table of Contents I. Background and Introduction... 1 II. Statutory
Accountable Care Organizations: Summary and Analysis of the Final Rule By Kathleen Kimmel, Chief Nursing Officer Greg Kotzbauer, Director of Product Management Ken Perez, Senior Vice President of Marketing
Using the MSSP ACO Model as a Pathway Towards Risk Contracting Hymin Zucker MD, CMO & Amy Holm, MHA Triple Aim Development Group November 12 th 13 th 2015 Extinction/Volume Evolution/Value 1 Disclaimer:
Steven E. Ramsland, Ed.D., Senior Associate, OPEN MINDS The 2015 OPEN MINDS Performance Management Institute February 13, 2015 10:15am 11:30am The execution or accomplishment of work, acts, or feats The
IAMSS 30 th Annual Education Conference Pearls of Wisdom The Impact of Accountable Care Organizations (ACOs) and Health Care Reform on Credentialing, Privileging and Peer Review April 28-29, 2011 Michael
The Accountable Care Organization Kim Harvey Looney kim.looney@ 615-850-8722 3968555 1 ACOs: Will I Know One When I See One? Relatively New Concept Derived from Various Demonstration Programs No Set Structure
Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION At the end of this session, you will be able to: Identify ways RT skills can be utilized for
NAVIGATING ALTERNATIVE PAYMENT MODELS 2016 Annual Meeting Kansas Grown: Strong, Healthy & Caring Overland Park, KS Learning Objectives Aledade will be presenting on how partnering with our company helps
Summary of Medicare s Request for Information on the Provisions in MACRA which Allow for Implementation of Alternative Payment Models and a Merit-Based Incentive Payment System On September 28, 2015, the
Accountable Care Organization Refinement Brief The participants in the Medicare Shared Savings Program (MSSP), the Physician Group Practice Transition Demonstration (PGP-TD), and the Pioneer Accountable
April 2015 COMMENTARY HHS Announces Next Generation ACO Model of Payment and Care Delivery On March 10, 2015, the U.S. Department of Health and Human Services ( HHS ) announced the Next Generation Accountable
ACOs & ESCOs National Kidney Foundation of Illinois Interdisciplinary Nephrology Conference October 25, 2013 About Me Dan Viaches VP Corp. Development - DaVita 6 Years with DaVita - 5 Years center operations
Source: Health Law Reporter: News Archive > 2010 > 04/15/2010 > BNA Insights > Provider Participation in ACOs May Hinge on HHS Regulations Provider Participation in ACOs May Hinge on HHS Regulations 19