Breaking Down Barriers to Creating Safety Net Accountable Care Organizations

Transcription

1 Breaking Down Barriers to Creating Safety Net Accountable Care Organizations Stephen M. Shortell,* Ph.D., M.P.H., M.B.A. Blue Cross of California Distinguished Professor of Health Policy and Management Dean, UC Berkeley School of Public Health Ann Marie Marciarille, J.D. Visiting Assistant Professor, UC Hastings College of the Law Matt Chayt, J.D. UC Berkeley School of Law, Chief Justice Earl Warren Institute on Law and Social Policy Sarah Weinberger MBA/MPH Candidate 2012, UC Berkeley Haas School of Business & School of Public Health Grant support provided by Blue Shield of California Foundation *Not in attendance

2 Introduction Blue Shield of California Foundation funded an interdisciplinary study to: 1.develop, assess and pilot a safety net ACO readiness assessment instrument in two California counties, and 2.examine the legal and regulatory issues associated with ACO safety net formation. The project work has four primary components: the creation of the instrument, the pilot testing of the instrument, a series of three policy briefs, and a final conference this January.

3 Our Team UC Berkeley School of Public Health Stephen M. Shortell, Ph.D., M.P.H., M.B.A. Bahar Navab Sarah Weinberger UC Berkeley School of Law, Chief Justice Earl Warren Institute on Law and Social Policy Ann Marie Marciarille, J.D. Ann O Leary, J.D. Matt Chayt, J.D. Phyliss Martinez UC Berkeley Law School Research Assistants Noah Metz, Anita Pandhoh, Sam Stefanki, David Vernon

4 Project Advisory Committee Elaine Batchlor, LA Care Health Plan Andrew Bindman, UCSF School of Medicine Thomas S. Bodenheimer, UCSF School of Medicine Carmela Castellano-Garcia, California Primary Care Association Thomas L. Greaney, St. Louis University School of Law Timothy Jost, Washington & Lee School of Law Gerald F. Kominski, UCLA School of Public Health Marty Lynch, Lifelong Medical Care Carmen R. Nevarez, Public Health Institute James C. Robinson, UC Berkeley School of Public Health Patricia R. Terrell, Health Management Associates Tom Williams, Integrated Healthcare Association

5 Defining Terms We define the safety net broadly More than just government-funded insurance and county hospitals From a patient perspective, incorporating providers who accept sliding scale payments, or no payment at all (bad debt) for patients who cannot pay We define an ACO as a group of health care providers that: Are collectively responsible for, and held accountable to measures of, the health of a population they serve, and Have an organizational structure permitting encouragement of improvements in quality and lower costs through payment incentives.

6 The Burden for Safety Net ACOs Both patients and providers in the safety net have a lot to gain from the coordinated care strategies and financial incentives offered by ACOs During preliminary interviews, safety net providers expressed concerns about, e.g.: Scarce capital The complicated health issues of safety net patients The lack of information technology and infrastructure

7 Methodology Literature review of the current ACO readiness assessment AMGA ACO Readiness Assessment tools Brookings-Dartmouth ACO Learning Collaborative Toolkit CAPG Standards of Excellence The Dartmouth Institute s Survey for Providers about ACO Implementation Health Research and Educational Trust s Integration and Care Coordination Survey (AHA) MGMA Survey NCQA Draft ACO Criteria AltaMed Health Services Medical Services Initiative, Orange Outreach interviews to the CA safety net provider community California Association of Public Hospitals California Department of Managed Health Care California Primary Care Association CAP Management Systems, MedPOINT Management, and SynerMed Catholic Healthcare West Community Family Care IPA Daughters of Charity Health System Department of Health Care Services Eisner Pediatric & Family Medical Center Family HealthCare Network Hospital Council of Northern and County Health Care Agency Mission Neighborhood Health Center Natividad Medical Center Open Door Community Health Centers Redwood Community Health Coalition Safety Net Financing Division, Department of Health Care Services Santa Cruz County Health Services Agency Santa Rosa Community Health Centers UCSD Health Services West County Health Centers, Inc.

8 Instrument Logistics Qualtrics survey tool was used 87 questions* Written to be completed in 30 minutes Multiple individuals from across each organization were surveyed Survey takers record their responses on a scale of 1 to 9, where the meaning of each rating is explained separately for each question In the pilot phase, the survey was administered to two California counties *Built with internal skip logic, so survey takers were not asked to answer all 87 questions.

9 Instrument Overview Organizational Mission / Population Served Governance and Leadership Partnerships Finance and Contracts IT Infrastructure Managing Clinical Care Performance Reporting Legal / Regulatory Issues, Barriers, and Risk Tolerance Overall Assessment

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11 Preliminary Survey Results

12 Highest Readine ss Summary of Preliminary Survey Results Overall Assessment Lowest Readine ss Surveys Taken (N = 56) PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

13 Organizational Mission / Population Served Hypothesis: Organizations must conduct a significant amount of pre-work and planning, including understanding their population, providers, scope of services, and geographic coverage area Findings to date (N = 55) Mean: 5.8 Median: 5.8 Standard Deviation: 1.0 Range: [3.3, 8.0] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

14 Governance and Leadership Hypothesis: Organizations should build an appropriate governance structure and establish robust leadership across the organization Findings to date (N = 54) Mean: 5.1 Median: 5.0 Standard Deviation: 1.9 Range: [1.2, 9.0] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

15 Partnerships Hypothesis: Organizations will need to have strong partnerships across the care continuum and have partners who are willing to work together to provide cost-effective care to an ACO population Findings to date (N = 55) Mean: 5.1 Median: 5.0 Standard Deviation: 1.4 Range: [2.1, 9.0] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

16 Finance and Contracts Hypothesis: Organizations need to be ready to accept additional risk, have the capital to make upfront investments, manage contractual relationships, and distribute shared savings payments both within and outside of their potential ACO Findings to date (N = 55) Mean: 4.8 Median: 4.8 Standard Deviation: 1.4 Range: [1.0, 8.7] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

17 IT Infrastructure Hypothesis: Organizations need to have a robust IT infrastructure to be able to optimally manage its panel of ACO participants Findings to date (N = 54) Mean: 4.7 Median: 4.6 Standard Deviation: 1.6 Range: [2.0, 9.0] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

18 Managing Clinical Care Hypothesis: Organizations should have protocols in place to manage clinical care through ensuring patient access, cultural competence, visit management, care coordination, self-management and patient engagement, managing population health and prevention, and continuous improvement Findings to date (N = 54) Mean: 5.7 Median: 5.7 Standard Deviation: 0.9 PRELIMINARY Range: RESULTS-NOT [3.8, FOR FURTHER 8.0] DISSEMINATION

19 Performance Reporting Hypothesis: Organizations will need to be ready to report on a significant number of new metrics to CMS and other external parties Findings to date (N = 50) Mean: 5.2 Median: 5.1 Standard Deviation: 1.8 Range: [1.3, 8.3] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

20 Legal / Regulatory Issues, Barriers, and Risk Tolerance Hypothesis: Organizations must be aware of the legal/regulatory issues and barriers that they may face when becoming an ACO and work with their legal teams to determine their risk tolerance across a number of issues Findings to date (N = 56) Mean: 3.2 Median: 3.1 Standard Deviation: 1.4 Range: [1.0, 7.3] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

21 Overall Assessment Hypothesis: Organizations were asked to rate their overall readiness levels to become an ACO Findings to date (N = 48) Mean: 4.7 Median: 5.0 Standard Deviation: 1.8 Range: [1.0, 8.7] PRELIMINARY RESULTS-NOT FOR FURTHER DISSEMINATION

22 Legal and Regulatory Analysis

23 Why Legal and Regulatory Barriers? Our hypothesis is that organizations must be aware of the legal/regulatory issues and barriers that they may face when becoming an ACO and work with their legal teams to determine their risk tolerance across a number of issues. Initial findings from the population we surveyed suggest strikingly low confidence in handling these issues.

24 Legal and Regulatory Barriers Upon review of the originally proposed Medicare Shared Savings Program regulations, we submitted comments on the following areas: Full inclusion of FQHCs and RHCs in ACO formation Alleviation of operational requirements that disproportionately burden safety net providers Proper checks and balances on provider concentration Financial incentives expressly tailored to safety net ACOs Technical assistance for safety net ACOs Federal-state partnerships to address state-level

25 FQHCs and RHCs: What was the problem? Precluded from forming ACOs themselves Rationale for decision Critique of rationale We proposed that CMS find ways to adapt the available data to the needs of the MSSP until a sufficient backlog of HCPS data is available Existing Workarounds Existing Workarounds HCPCS

26 FQHCs and RHCs: What Is In the Final Rule? Eligible to form ACOs themselves CMS will perform a data cross-walk from revenue center codes already in use in order to align beneficiaries with FQHCs and RHCs.

27 Safety Net ACOs and Provider Compensation Our federal policy brief argued for more guidance on: The ACO self-dealing waiver and pre-existing exception for direct compensation arrangements, for reporting requirements CMP waiver s applicability to providers and suppliers outside the ACO Interim final rule expanded waivers to encompass more types of activity: ACO pre-participation, ACO participation, patient incentives

28 Safety Net ACOs and Fair Competition Measures to ensure safety net access to specialists should include the following: Rewards or incentives provided to specialists who participate in safety net ACOs FTC and DOJ should consider creating special fair competition zones for ACOs in rural areas Final policy statement from FTC/DOJ abandons mandatory antitrust review, but makes no other major changes

29 Safety Net ACOs and the IRS In our comments on the interim rules, we recommended that the IRS clarify rules with special attention to the needs of the safety net and to the potential problems when a nonprofit partners with a for-profit. The IRS has released a new fact sheet in conjunction with the final MSSP rule that warns charities to consult IRS guidance regarding joint ventures if engaging in non-mssp activities.

30 The Advance Payment Initiative: Opportunity for the Safety Net? The scoring criteria for evaluating applications will favor: ACOs with the least access to capital, ACOs that serve rural populations, and ACOs that serve a significant number of Medicaid beneficiaries. The Innovation Center is prepared to spend up to $170 million on as many as 50 participating ACOs.

31 Safety Net ACOs: A California Perspective We are about to publish a state-focused brief arguing for measures that state policymakers can take to encourage safety net ACOs. Key issues from the state policy perspective include: the need to clarify applicable state regulations (i.e., the Managed Care Liability Act), the role of independently licensed providers, and the corporate practice of medicine doctrine. Our brief also examined safety net ACO initiatives in Colorado and New Jersey.

32 Next Steps Completion of pilot testing of survey instrument and analysis of results Third policy brief Conference at UC Berkeley on January 27, 2012, to discuss the final results and policy / practice implications For more information, contact Matt Chayt: mchayt@law.berkeley.edu,

33 This project was made possible by Blue Shield of California Foundation. We thank them for their support.

34 Thank You! Healthier Lives In A Safer World