Mary Washington Health Alliance. Frequently Asked Questions

Transcription

1 Mary Washington Health Alliance Medicare Shared Savings Program (MSSP) Frequently Asked Questions 1. What is an ACO and what is the MSSP? An Accountable Care Organization (ACO) is a provider organization based on the philosophy of clinical integration. To the extent the Alliance engages private payers and employers under shared savings models; it would be participating in a form of accountable care. The MSSP is a program launched by CMS to utilize accountable care in Medicare, and organizations wishing to be treated as ACOs for Medicare purposes must participate in the MSSP. 2. Notice of Intent to Apply and Application Process Timelines The Alliance Board of Managers agreed to complete a Notice of Intent by May 30 th. This Notice of Intent is non-binding upon the Alliance, but it ensures that we will have the opportunity to evaluate whether to apply to participate in the MSSP as of What is the difference between application to and acceptance in the Medicare Shared Savings Program (MSSP)? There are 2 phases to the MSSP application cycle for program year The 1st phase is the Notice of Intent to Apply, a non-binding and relatively short questionnaire with a 1 month application window. The 2 nd phase is the formal, and much more comprehensive, Application Process and this package is due on July 31, 2014.

2 4. What is the length of time the Alliance would need to commit to as part of the MSSP? Acceptance and participation in the program requires a 3 year commitment, and the Alliance would have the option to continue with the program after 3 years or drop-out at that time. 5. How will my practice benefit from participation in the MSSP? CMS will 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. 6. Is there any downside financial risk to the Alliance or to the individual physician? 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 accept the one-sided model for the first agreement period of three years. Because the Alliance is opting for the one-sided model this means it is an upside only model for the initial 3 year term of the agreement and there is no down side risk to the agreement. 7. How many Primary Care Physicians are in Mary Washington Healthcare s market, and how many of those are Alliance Physicians? There are approximately 220 Primary Care Physicians in Mary Washington s primary service area, and the Alliance has 97 Primary Care Physicians in the Network. That is 44% of the community Primary Care Physicians in the Alliance. 8. What is the rule on provider exclusivity under the Medicare Shared Savings Program? The Medicare Shared Savings Program requires that each Accountable Care Organization (ACO) participant TIN upon which beneficiary assignment is dependent must be exclusive to one Medicare Shared Savings Program ACO. This means that a taxpayer identification number (TIN) or CMS Certification Number (CCN) billing Medicare for primary care services must be exclusive to one ACO s certified list of ACO participants. A TIN or CCN may appear on the certified list of ACO participants for multiple ACOs only if it doesn t bill Medicare for primary care services.

3 Under the Medicare Shared Savings Program rules, ACOs submit a certified list of ACO participants at the beginning of each performance year and at such other times as specified by CMS. CMS uses this list for assignment, benchmarking, developing the sample for quality reporting, and other important program operations. Any ACO participant that bills for primary care services must be exclusive to a single Medicare Shared Savings Program ACO to make sure each ACO has a unique list of assigned beneficiaries (i.e.: practices with a shared TIN). Accordingly, specialists who practice under the same umbrella as primary care physicians would need to be exclusive to the Alliance s ACO, even if the specialists do not bill for primary care services. Note: This exclusivity rule applies to the Medicare-enrolled billing TIN that is an ACO participant in the ACO, not to individual practitioners. Individual practitioners are free to participate in multiple ACOs if they bill under several different TINs, through two separate practice entities, for example. The implications of doing so may be significant and should be carefully evaluated. Also, the exclusivity rule applies only for Medicare Shared Savings Program operational purposes. In no way does it establish or otherwise imply a lock in of beneficiaries or a limitation of provider practice or referrals. 9. What Quality measures will I be held accountable to? ACOs will be held accountable for 33 quality metrics over 8 domains. Patient/Caregiver Experience (7) Care Coordination/ Patient Safety (6) Preventive Health (8) At Risk Population Diabetes (6) At Risk Population Hypertension (1) At Risk Population Ischemic Vascular Disease (2) At Risk Population Heart Failure (1) At Risk Population Coronary Artery Disease (2) See appendix #1 for the specific metrics, which fall under the domains listed above. 10. What is the minimum number of Medicare beneficiaries needed to start a MSSP program? An ACO needs to have at least 5,000 preliminarily assigned beneficiaries in order to be in the MSSP in each of the three years preceding the start of the agreement period (2011, 2012, and 2013). A beneficiary assigned in one year of the program may or may not be assigned to the same ACO in the following or preceding years.

4 11. How will patients be assigned to physicians? If a beneficiary meets the eligibility criteria, the beneficiary is assigned to an ACO using a twostep process: CMS will assign a beneficiary to a participating ACO when the beneficiary has at least one primary care service furnished by a primary care physician at the participating ACO, and more primary care services (measured by Medicare allowed charges) furnished by primary care physicians at the participating ACO than from primary care physicians at any other Shared Savings Program ACO or non-aco individual or group TIN. This step applies only for beneficiaries who haven t gotten any primary care services from a primary care physician. CMS will assign the beneficiary to the participating ACO in this step if the beneficiary got at least 1 primary care service from a physician at the participating ACO, and more primary care services (measured by Medicare allowed charges) from ACO professionals (physician regardless of specialty, NP, PA, or CNS) at a participating ACO than from any other ACO or non-aco individual or group TIN. 12. What is the value in the data made available by CMS as a part of the MSSP? Once accepted into the program, MSSP-participating ACOs receive from CMS, all claims data for the ACO s attributed beneficiaries. This data is comprehensive in nature and is similar to the data we have been analyzing for the MWHC employee health plan. Using this data, we can identify opportunities for cost savings as well as quality improvement for the Medicare population we serve.

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