Theresa Dolan COO Mount Sinai Care April 25, 2014

Transcription

1 Stephen Nuckolls CEO, Coastal Carolina Health Care, P.A Jeff Spight SVP, ACO Market Operations Universal American Theresa Dolan COO Mount Sinai Care April 25, 2014

2 Overview of the ACO Beneficiary Assignment 1. Prospective vs. Retrospective Assignment 2. 2 Step Beneficiary Assignment Process 3. CMS Provided Examples 4. CHS/Universal American Experience 5. Survey Results 6. Lessons Learned 7. Q and A

3 Coastal Carolina Health Care, PA 12 Clinic Locations 50+ Providers (60% PCP) Internal Medicine Family Practice Emergency Medicine Cardiology Endocrinology Hematology/Oncology Gastroenterology Neurology Pulmonary/CC Rheumatology Imaging Center Urgent Care Sleep Lab GI ASC Integrated Enterprise wide EHR All Providers are Meaningful Users of EHR Experience with Population Health Management and Reporting 3

4 ACO 100% Owned by Medical Practice Started Program April 1, ,000+ Attributed Beneficiaries $100 Million Estimated Claims Budget Advanced Payment Model ACO 11 Care Managers and Data Analyst 4

5 ACO Beneficiary Assignment

6 ACO Beneficiary Assignment Prospective Assignment Advantages Beneficiaries are known in advance Help with outreach and assignment of resources Disadvantages No control if they leave area No assignment for new patients Perhaps more focus on specific beneficiaries than delivery system change

7 ACO Beneficiary Assignment Preliminary prospective assignment with final retrospective beneficiary assignment Beneficiary assignment is determined in the benchmark years of the agreement period and then re determined retrospectively at the end of teach performance year. Quarterly preliminary prospective assignment supports quarterly reports and ACO operations A beneficiary assigned in one quarter or year of the program may or may not be assigned to the same ACO in the following preceding quarters/years

8 Beneficiary Assignment Schedule CMS makes preliminary beneficiary assignments to ACOs at the beginning of each performance year based on the most recent four quarters of available data. On rolling four quarter basis, CMS assigns patients to ACOs, and provides updated lists of beneficiaries. Final assignment for financial reconciliation is determined after the performance year based on claims data with a 3 month run out.

9 Assignment Data Requirements List of ACO participants Names and identifiers (Taxpayer Identification Numbers (TIN), CMS Certification Numbers (CCN) Identifiers are needed to identify claims submitted by the ACOs Identifiers are verified using PECOS and other CMS data systems

10 Assignment: Beneficiary Eligibility A beneficiary is eligible to be assigned to a participating ACO if the following criteria are satisfied during the assignment period: Beneficiary must have a record of Medicare enrollment Beneficiary must have at least one month of Part A and Part B enrolment, and cannot have any months of only Part A or Part B

11 Assignment: Beneficiary Eligibility Beneficiary cannot have any months of Medicare group (Private) health plan enrollment Beneficiary must reside in the United States including Puerto Rico & Territories Beneficiary must have a primary care service with a physician at the ACO

12 Assignment of Beneficiaries If a beneficiary meets the eligibility criteria, the beneficiary is assigned to an ACO using a two step process: Step (1): If the beneficiary has at least one primary care service, and overall the plurality of their primary care services furnished by a primary care physician at the participating ACO (measured by Medicare allowed charges), then the beneficiary is assigned to the that participating ACO.

13 Assignment of Beneficiaries, Cont. Step (2): Applies to beneficiaries who have not received any primary care services from a primary care physician. If the beneficiary has at least one primary care service furnished by a physician at the participating ACO. And has received more primary care services from ACO professional (physician regardless of specialty, NP, PA, or CNS) (Measured by Medicare allowed charges) relative to any other ACO or non ACO individual or group, the beneficiary is assigned to that participating ACO.

14 Individual Provider Types Primary Care Physicians (PCP) Internal Medicine Family Practice General Practice Geriatric Medicine Other physicians (MD, DO) ACO Professionals include both the above types of physicians plus: Nurse Practitioners (NP) Clinical Nurse Specialist (CNS) Physician Assistant (PA)

15 Definition of Primary Care Services Evaluation & Management Services provided in: Office or Other Outpatient settings (CPT ) Nursing Facility Care settings (CPT ) Domicilary, Rest Home, or Custodial Care settings (CPT ) Home Services (CPT ) Wellness Visits (HCPCS G0402, G0438, G0439 Clinic visits at RHC/FQHCs or by their providers in selected settings (UB revenue center codes 0521, 0522, 0524, 0525

16 Notes for Following Examples Organizational ID Is the A# for each ACO all TINs and CCNs on an ACO s participant list are associated with the ACO s A# TIN or CCN for non ACO practices and providers For each beneficiary assignment example, the top row indicates the ACO or non ACO provider to which the beneficiary was assigned

17 ACO Assignment Example 1 Allowed Charges for Primary Care Services Beneficiary Org 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 provided by a primary care physician (454) even though two other non ACO practices had higher allowed charges provided by ACO professionals

18 ACO Assignment Example 2 Allowed Charges for Primary Care Services Beneficiary Org ID PCP ACO Professional B $1,200 $1,250 B3 A5656 $800 $800 B3 A9999 $600 $700 Beneficiary B3 is assigned to a non ACO provider ( ) because it had the highest allowed charges for primary care services provided by a primary care physician ($1,200).

19 ACO Assignment Example 3 Allowed Charges for Primary Care Services Beneficiary Org ID PCP ACO Professional A3 A9999 $0 $300 A $0 $250 A $0 $200 Beneficiary A3 did not receive any primary care services from a primary care physician. So A3 is assigned to ACO A9999 on the basis of the highest allowed charges for primary care services provided by ACO professionals ($300)

20 Attribution Within the ACO Advantages of Provider Attribution (Accountability) Quality measures Resource utilization How to Attribute Patients Claims Data Practice Management System(s)/EHR/Registries

21 Mount Sinai Care s Experience

22 Mount Sinai Care s ACO The Mount Sinai Health System Mount Sinai Care Faculty Practices Employed Network Practices Hospital-based Practices 26 Practices 24 Care Coordinators 280 Primary Care Physicians 5 EMRs 32,000 Beneficiaries Acute Patient Population 22

23 Mount Sinai s Experience with Attribution Impact of Academic Medical Center Fluidity of Patients Aligned with ACO because of Specialty Care Cancer Treatment Transplants Other NYC and Physician Shopping Geographic Transitions Snowbirds Clinical Status Transitions 23

24 24 Universal American s Experience

25 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 Only 58% of Beneficiaries Assigned to one of our ACOs Preliminary Prospective Roster Were Assigned in Q ,242 PPR (as of 12/11) Quarterly Population Assignment Status Leaver Beneficiary Removed from ACO New/Continuous Newly Assigned Prelim Prospective Roster 5,121 5,562 7,757 9,857 10,621 10,477 22,121 Q2 12 (as of 6/12) 7,827 20,513 10,275 19,118 18,292 12,793 16,187 19,167 10,988 16,365 15,934 Only 58% of Preliminary Prospective Roster attributed Q3 12 Q4 12 PY1 Interim Q1 13 Q2 13 Q3 13 Trended BM $ Source: CHS Analysis of 2013 CMS Claims Files and ACO Rosters received through November 2013.

26 CHS Experienced Similar Churn Across All 4/1 Starts Nine MSSP ACOs that started on 4/1/12 and accounted for 89,888 patients experienced 39.3% aggregate attrition of patients from our preliminary prospective roster. ACO Active in Q42013 ACO Roster PPR (Initial) ACO Roster %PPR Leavers as of Q42013 A % B % C % D % F % G % H % I % J % TOTAL 54,556 89,888 39% 26 Source: CHS Analysis of 2013 CMS Claims Files and ACO Rosters received through November 2013.

27 NAACOS Survey

28 Survey Data We received 50 survey responses ACO Start Dates 2 January 1, April 1, July 1, January 1, January 1, 2014

29 Claims Data Sharing Opt Outs 40 ACOs submitted data Rage of results was from.4% to 54.0% Mean = 5.3 Median = 3.0

30 Why Reduce Opt Outs? Increase Claims Data Data to help determine how ACO cost and utilization programs are performing Selecting patients for care management Input data in electronic chart or registries Increased accuracy of distribution formulas

31 Strategies to Reduce Opt Outs Maintain Structured Data in Practice Management System Educate Staff, especially front desk Reach Out to Patients

32 Patient Attribution Survey Data Excluded Pioneer ACO responses as they have a prospective attribution model that excludes deceased beneficiaries ACO s did not have enough data to complete Some ACO s elected not to complete this section or submitted incomplete data. Final sample size of 15.

33 Changes in Beneficiary Attribution Beneficiary Count January 1, 2013 Newly Attributed Beneficiaries Deceased Beneficiaries Beneficiaries No Longer Attributed Beneficiary Count December 31, 2013 XX,XXX X,XXX (XXX) (X,XXX) XX,XXX

34 How Calculated Beginning Beneficiary Total was obtained from Table 1 1 of the Q Assigned Beneficiary Report by subtracting beneficiaries with a Deceased Beneficiary Flag = 1 from the total number of beneficiaries. Newly Attributed Beneficiary total was obtained by combining beneficiaries from Table 1 1 of the Q1 Q4 Assigned Beneficiary Report with a Previously Assigned Beneficiary Flag = 0.

35 How Calculated Deceased Beneficiary total was obtained by combining deceased beneficiaries from Table 1 1 from the Q1 Q Assigned Beneficiary Report into one spreadsheet and then subtracting duplicates before computing the total. The Ending Beneficiary Total was obtained in the same fashion as the beginning by subtracting the deceased beneficiaries from Table 1 1 of the Q Assigned Beneficiary Report. The total of beneficiaries no longer attributed was computed from the other figures obtained above.

36 Survey Results Median Mean Beneficiary Count January 1, ,688 16,107 Newly Attributed Beneficiaries 3,025 4,194 Deceased Beneficiaries (978) (1,237) Beneficiaries No Longer Attributed (168) (1,960) Beneficiary Count December 31, ,567 17,104

37 Survey Results Median Mean Overall Change in Beneficiary Count 1.3% 3.7% Newly Attributed Beneficiaries 25.0% 27.9% Deceased Beneficiaries 7.0% 7.5% Beneficiaries No Longer Attributed 18.0% 16.7%

38 Recent Data on ACO Turnover* 80.4% of Beneficiaries attributed in 2010 were also attributed in % of Beneficiaries were consistently assigned in both 2010 and % of office visits with PCP were outside of assigned ACO. Higher turnover for healthier patients and also for patients with several high cost conditions and highest decile of per beneficiary spending.

39 Recent Data on ACO Attribution* 66.7% of office visits with specialists were provided outside of the assigned ACO. (Specialty care leakage was greater for higher cost beneficiaries and was substantial even among specialty oriented ACOs (54% for lowest quartile of primary care orientation) 37.9% of total outpatient care was paid to ACO physicians. This proportion was higher for ACOs with greater primary care orientation (66.0% for highest quartile vs 33.6% for lowest.) *Outpatient Care Patterns and Organizational Accountability in Medicare. McWilliams, MD, PHD, et al. JAMA Intern Med. Published online April 21, 2014.

40 Top Reasons for Drop Off No appointment in last 12 months Plurality of visits with another provider Enrolled in Medicare Advantage Moved Died Part A Only

41 Strategies to Maintain Assignment Annual Wellness Visit (Billed Under MD) Increased Access (After Hours Care) Increased Specialty Providers Increased Use of Transitions of Care Codes Add Urgent Care Centers as Participants?

42 Summary There are tradeoffs between prospective and retrospective assignment Model will likely evolve Goal is delivery system reform and move to value

43 Questions? 43