The Commonwealth of Massachusetts Executive Office of Health and Human Services One Ashburton Place, 11 th Floor Boston, MA 02108

Transcription

1 DEVAL L. PATRICK Governor TIMOTHY P. MURRAY Lieutenant Governor The Commonwealth of Massachusetts Executive Office of Health and Human Services One Ashburton Place, 11 th Floor Boston, MA JUDYANN BIGBY, M.D. Secretary June 3, 2011 To All Interested Parties: The Commonwealth of Massachusetts Executive Office of Health and Human Services (EOHHS) is issuing this Request for Information (RFI) to solicit information from a broad spectrum of interested parties regarding the initiative by state payers to use accountable care organizations (ACOs) throughout the Commonwealth to increase the coordination and delivery of integrated health care services, as defined in this RFI. EOHHS is evaluating the issues raised by a transition to ACOs, and seeks to obtain additional information from interested parties as part of its evaluation process. EOHHS seeks to encourage ACO formation in order to improve care delivery, coordination, and quality, and to be able to utilize alternatives to fee-for-service payment methods to compensate ACOs in a manner that will decrease total per capita expenditures, and the rate of growth in expenditures for health care in the Commonwealth. Information received in response to this RFI may be used by EOHHS and other state health purchasing agencies (including but not limited to the Connector Authority, the Group Insurance Commission, Department of Workforce Development) for developing one or more ACO procurement and contracting initiatives. EOHHS seeks comments from all interested parties, including physicians, health care organizations and delivery systems and other providers, purchasers of health care, carriers and health plans, as well as consumers, in order to develop a comprehensive plan to improve health care quality and delivery of integrated services while decreasing costs over the long term. EOHHS recognizes and anticipates that there will be ACOs of different levels of integration, structures, and sizes, and seeks input on ways to promote the development of a variety of ACOs throughout the Commonwealth. EOHHS further recognizes that a transition to the formation and use of ACOs will affect the relationship between payers and providers, and seeks to elicit comments on that transition as well. The initiative to promote ACO development is part of a broader effort to transform the health care system in Massachusetts by restructuring the delivery of care and changing reimbursement for health care services. Massachusetts reform efforts include initiatives to develop patient-centered medical homes and changing the way primary care is reimbursed, bundled payments, integrated care models for the provision of services to individuals eligible for both Medicaid and Medicare (Dual Eligibles), and pending state legislation to promote ACOs and a multi-payer transition to the use of alternative Accountable Care Organizations RFI 1

2 payment methodologies throughout the Commonwealth. Through these initiatives, Massachusetts seeks to support access to health care services across the continuum of care, improve care coordination across the health care delivery system, and create payment systems that hold health care providers accountable for the care they deliver. The goal is to reward quality, coordinated and integrated care that prioritizes the promotion of wellness as well as the treatment of illness and injury and to do so while optimizing efficiency and cost containment within the health care system. The federal government, through its Centers for Medicare and Medicaid Services (CMS) recently issued proposed regulations for the Medicare Shared Savings Program under the Patient Protection and Affordable Care Act (section 3022). The Commonwealth intends to take into account the federal rules in its ACO planning efforts, and EOHHS will continue to monitor CMS regulatory process. Where this RFI and any resulting procurements represent a state initiative, the Commonwealth may decide to adopt a different approach from that set forth in the proposed federal regulations. Please feel free to respond to only those questions on which you would like to provide input. The questions set forth in Section III.O. are specifically addressed to health plans. EOHHS will accept responses to any or all of the questions in Section III and IV. Please submit your response, according to the instructions provided in Section V, by July 13, We encourage you to respond and thank you in advance for your participation. Sincerely, JudyAnn Bigby, M.D. Secretary Accountable Care Organizations RFI 2

3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES OFFICE OF MEDICAID ONE ASHBURTON PLACE, 11 TH FLOOR BOSTON, MA REQUEST FOR INFORMATION REGARDING ACCOUNTABLE CARE ORGANIZATIONS Improving Health Care Quality, Delivery of Integrated Services, and Containing Costs through Accountable Care Organizations ISSUED: JUNE 3, 2011 DOCUMENT # 11LCEHSACCTCAREORGRFI Accountable Care Organizations RFI

4 TABLE OF CONTENTS SECTION I. Background...1 SECTION II. Definitions...1 SECTION III. Questions for Response...3 SECTION IV. RFI Respondent Information...11 SECTION V. RFI Response Instructions...12 SECTION VI. Additional RFI Information...13 ATTACHMENT A: ACO RFI Response Template Accountable Care Organizations RFI

5 SECTION I. Background The Patient Protection and Affordable Care Act ( Act ), which was signed into law on March 23, 2010, seeks to improve the overall quality of health care delivered while reducing health care costs. More specifically, the Act calls for the formation of accountable care organization ( ACO ) pilots and other programs. Additionally, the Act specifies for some programs that ACOs, and the healthcare providers that are part of an ACO, may share in cost savings if they meet certain performance standards while decreasing costs. The goal of establishing ACOs is to couple health care system delivery integration and payment reform by creating healthcare provider organizations with incentives to improve quality of care and control costs. The establishment of ACOs is viewed as way to provide high quality and more cost-effective care. Several states are currently in the process of assessing how to promote the formation of ACOs. In Massachusetts, Chapter 305 of the Acts of 2008 initiated the creation of a Special Commission on the Health Care Payment System ( Commission ), to investigate reforming and restructuring the system to provide incentives for efficient and effective patient-centered care and to reduce variations in the quality and cost of care. (St. 2008, chapter 305, 44). In July 2009, the Commission issued a report recommending that the state transition from fee-for -service to global payments as the dominant payment model for health care services in Massachusetts. The report also contemplated that the transition to global payments would be accompanied by the creation of ACOs to provide and coordinate cost-effective and quality primary care. On February 17, 2011, Governor Patrick filed a bill entitled An Act Improving the Quality of Health Care and Controlling Costs by Reforming Health Systems and Payments (Bill). The Bill is pending with the legislature, and has not yet been enacted. It establishes a framework for the formation of ACOs and a transition to alternatives to fee-for-service payments for ACOs and other integrated care organizations. In addition, MassHealth and other state health programs intend to develop a mechanism for working with providers, carriers, health plans and others who want to participate in alternative payment demonstrations with the goal of improving care coordination for MassHealth members as well as promoting better health outcomes and effectiveness. This RFI seeks to elicit input on issues that may be raised by policies relating to ACO formation. SECTON II. Definitions The following terms are defined below for purposes of this RFI, and are consistent with the definitions and requirements used in the Bill. In order to qualify as an ACO, an organization will need to meet the requirements for a Patient Centered Medical Home, and possess or contract for the additional functional capacities for operating as an ACO. An ACO will need to be able to provide all Integrated Health Care Services, as defined below. Payers will need to be able to offer methods of paying ACOs that are not solely fee-for-service based payments, and are Alternative Payment Methods. EOHHS seeks comments on these definitions, as further indicated in Section III, below. Accountable Care Organizations RFI 1

6 A. Accountable Care Organization or ACO 1. An entity comprised of health care provider groups which operates as a single integrated organization that accepts at least shared responsibility for the cost and primary responsibility for the quality of care delivered to a specific population of patients cared for by the groups clinicians; which operates consistent with principles of a patient centered medical home, has a formal legal structure to receive and distribute payments; and complies with any federal requirements applicable to ACOs, however named, which have been or may be enacted or adopted in law or regulation or referenced in an administrative bulletin. 2. ACOs must have or obtain through contractual arrangement or demonstrate plans to perform the following functional capacities: a. Clinical services coordination, management, and delivery functions, including the ability to provide Integrated Health Care Services through its ACO provider network in accordance with the principles of a Patient Centered Medical Home; provided further, that ACOs shall be required to provide primary care coordination and referral services internally and not solely through contracts; b. Population management functions, including health information technology and data analysis tools to provide at least: (i) patient-specific encounter data; and (ii) management reports on aggregate data; c. Financial management capabilities, including but not limited to claims analytics and tracking functions for ACO network providers; d. Contract management capabilities, including but not limited to network provider creation and management functions; e. Quality measurement competence, including but not limited to the ability to measure and report performance relative to established measures of quality and performance under standardized quality measures; f. Patient and provider communications functions; and g. The ability to provide behavioral health services either internally within the ACO or by contractual arrangement. B. Alternative Payment Methods or Methodologies Methods of payment that are not fee-for-service based and compensate ACOs and other providers for the provision of health care services, including but not limited to shared savings arrangements, bundled payments, episode-based payments, and global payments. No payment based on a fee-for-service methodology shall be considered an alternative payment methodology. Accountable Care Organizations RFI 2

7 C. Integrated Health Care Services Health care services relating to the treatment of certain conditions, including at a minimum all conditions required to be covered under regulations of the commonwealth health insurance connector authority defining the core services and a broad range of medical benefits required for minimum creditable coverage. D. Patient-Centered Medical Home The Patient Centered Medical Home is a model designed to promote comprehensive, coordinated, patient-centered care delivered by multi-disciplinary teams, including physicians and nurses. In a patient-centered medical home, a primary care provider and members of his or her team coordinate all of a patient's health needs, including management of chronic conditions, visits to specialists, hospital admissions, and reminders about appointments and tests. The medical home model supports fundamental changes in primary care service delivery and payment reforms, with the goal of promoting good health and improving health care quality. For more information about EOHHS patient-centered medical home initiative, please see the following link: s=closed&docuserid=3172&docviewtype=closed&docid=121435&dovalidatetoke n=false&soltypecd=universal (Request for Responses (RFR) for Multi-payer Patient- Centered Medical Home Services, Document #:1LCEHSMEDICALHOMES, Fourth Amended and Restated Version: August 13, 2010.) SECTION III. Questions for Response A. Definitions; ACO Structure and Services 1. How will providers form ACOs in a manner that complies with the above definitional requirements? 2. What issues are raised by the above definition that may interfere with or otherwise affect ACO formation? 3. The definition of Integrated Health Care Services as set forth in Section II does not include all Medicaid covered services. Should this definition be expanded to include additional, or all, Medicaid covered services? As a related matter, should an ACO that contracts with the state Medicaid agency include (and be able to satisfy all ACO requirements indicated in Section II. above for) additional, or all, Medicaid covered services, including dental, long term care services and supports, and other Medicaid covered services? 4. Should knowledge of and capacity to refer to and support community-based services and activities that promote or encourage wellness be included as part of the required core ACO capacities? Accountable Care Organizations RFI 3

8 B. Stakeholder Collaboration 1. How might the state, providers, patients and consumer groups, payers, and other health care stakeholders work together to promote the formation of ACOs and the ongoing adoption of the ACO delivery model as a mechanism to improve quality and coordination of care? 2. How should EOHHS and other state health purchasing agencies market and communicate the nature of the transition to ACOs to publicly insured individuals? 3. How will the transition to the use of ACOs affect the relationship between payers and providers? What new arrangements between payers and providers may arise as a result of this transition? 4. How can meaningful partnerships be built between ACOs and non-clinical community services and neighborhood-based agencies to promote healthier conditions in patients lives? C. ACO Formation 1. How could EOHHS and other state health purchasing agencies encourage ACO formation? 2. What potential challenges do the definitional requirements set forth in Section II above pose for providers interested in forming an ACO? How can those challenges be addressed? 3. What steps are needed for multiple providers operating as Patient-Centered Medical Homes to become an ACO? How can primary care remain at the core of the organizational structure, as providers form more integrated organizations and arrangements? 4. What types of incentives would best promote ACO formation? Other than financial incentives, are there specific items that would, if established, operate to encourage healthcare providers to form ACOs? 5. How should ACOs demonstrate that they have the clinical coordination, population management functions, financial and contract management capabilities, quality measurement competence, patient and provider communications functions, and the ability to provide specialty services, including behavioral health services that are needed to operate as an ACO? 6. What policies could EOHHS consider that might help small and individual practitioners to participate in ACOs? Accountable Care Organizations RFI 4

9 7. How should ACOs ensure that their policies and decision-making processes promote the best health outcomes for the patients they serve? 8. In addition to core clinical staff and services, should other types of employees and/or services be utilized to assist in preventing illness and injury and promoting good health? If so, what other types of employees and/or services would be needed? 9. What structural, organizational, clinical, financial, legal, geographic, or other issues may pose barriers to ACO formation? 10. Are there geographic or regional differences in readiness to transition to an ACO? If so, what can be done to address these barriers? 11. What should the method be for assigning or attributing individuals to an ACO? D. Transition Period There may be a transition period as health care providers form or join more integrated organizations. The following questions address issues that may arise during the transition to ACO formation. 1. What types of transitional programs (e.g. system delivery pilots, interim alternative payment programs) would be most helpful to encourage and support ACO formation and success during this period? 2. Certain healthcare providers may require technical and infrastructure development processes to transition into ACOs. a. Please describe any areas of technical and infrastructure development processes providers will need to make this transition. b. What specific assistance may be needed to help providers that want to participate in an ACO be able to do so? c. Are there types of assistance other than financial help that will be useful to providers? d. What types of assistance will providers need to be able to measure, track, report on, and meet identified quality and performance measures? 3. What are the anticipated costs of transformation to an ACO? Accountable Care Organizations RFI 5

10 E. ACO Organization and Governance 1. What parameters, if any, should be established regarding ACO organization and governance? 2. What kinds of structures are needed to ensure appropriate integration, coordination, and quality of care for patients in an ACO? 3. How should ACOs include consumer representation in their organizational governance? What consumer protections are needed in the transition to ACOs, and how should they be implemented? What mechanisms to ensure consumer engagement should be established? 4. How should ACOs ensure that their decision-making reflects the views of its network providers? F. Care Coordination; Performance Measures 1. How can ACOs demonstrate improved coordination of care delivery? 2. Payments to ACOs may be based at least in part on achievement of measures of performance and outcomes. This could be measured in a number of ways, including but not limited to demonstrating improved access to care, quality of care and outcomes, and patient satisfaction. What quality and other measures should be considered as part of performance? How should they be established? 3. How should EOHHS assess patient and provider experience as a measurement of ACO performance? 4. Since the primary goal of the ACO is to promote good health through improving the quality and coordination of care delivered, how might ACOs be incentivized to improve both the quality and coordination of care delivered by the ACO? 5. Are there particular measures that would capture health promotional or disease prevention efforts both in traditional and non-traditional settings and with multidisciplinary staff? G. Data Collection and Publication EOHHS and the other state health purchasing agencies would need evidence to support the effectiveness of ACOs and payment reform, and would need to carefully document metrics and outcomes. Data reporting must be timely to meet these requirements. Encounter level data and other reports would be required for all encounters (e.g., administrative, financial, and quality reports), including those provided by subcontractors and ACO network providers (providers that by contract or corporate structure participate in a specific ACO). Accountable Care Organizations RFI 6

11 1. EOHHS seeks to improve the collection and transparency of data relating to both the quality and cost of care. What would be the optimal means of collecting, analyzing, and publishing data regarding the achievement of quality measures, disease prevention and health promotion, patient satisfaction, cost, payments by providers and payers, and other relevant information? 2. What data should the ACO be required to submit to the payer? How could ACOs and providers partner with payers to create streamlined data collection and reporting processes? a. Please comment on any issues that may be a barrier to complying with data requirements and strategies to address potential barriers. b. What potential health information technology, data, and/or reporting infrastructure needs may have to be addressed in support of ACO operations and patient care coordination? c. Would a provider need any data other than its own in order to form and operate as an ACO? How could privacy issues be addressed? Please include specifics about any data exchanges that would need to be established. 3. What is the minimum necessary data providers would need to prepare a response to a procurement soliciting bids for ACOs to contract with the state to provide health care services for publicly insured individuals? 4. What financial information would be helpful when preparing a response to such a procurement? H. Payments/Savings and Financial Administration ACOs may need to be prepared to accept Alternative Payment Methodologies, as defined in Section II. EOHHS plans to utilize contracting mechanisms that reward high-quality performance and health outcomes. 1. What services should be included in risk based reimbursement? Please explain if any services should not be reimbursed on a risk basis, and why. 2. How will these Alternative Payment Methodologies affect the way in which ACOs are formed? 3. What kinds of financial arrangements should be used to compensate ACO network providers? Please propose options as to how the money would flow from the ACO to the ACO network providers. 4. How should the ACO track spending for patients served by ACOs when they receive care outside of the network? Accountable Care Organizations RFI 7

12 5. How should the costs of care for patients that go out of the ACO for care be handled? What incentives should the ACO consider to keep patients from going outside the ACO for care? 6. What key challenges might ACOs face in administering alternative forms of payment, including reimbursement to individual ACO providers where bundled or global payments are made to the ACO? How can ACOs ensure new payment methodologies meet the needs of ACO network providers? 7. In the long term how do you envision payment trends changing? I. ACO Risk EOHHS envisions that ACOs could take on several levels of risk. The first level is financial risk based on performance, where providers forgo payment if certain clinical performance criteria are not met. The second (and higher) level is insurance risk, where ACOs assume full risk for all care for patients. 1. What criteria should be used to evaluate the ability of an ACO to take on financial risk? What controls are necessary to ensure that ACOs do not take on excess risk but are encouraged to take on appropriate performance risk? 2. What policies are needed to ensure that ACOs do not incur excessive costs due to catastrophic or other expensive, unforeseen patient care? 3. EOHHS anticipates that payments to ACOs will be risk adjusted to help protect ACOs from excess financial harm due to high cost patients or other factors. What types of risk adjusters should be used to adjust global and other alternative payment methods, to help protect ACOs from taking on excess risk? 4. Should ACOs be required to have a minimum number of beneficiaries? 5. Should ACOs/providers contract directly with MassHealth and other state health purchasing agencies to deliver integrated care? What policies and procedures are necessary to facilitate this strategy? J. Access 1. How should ACOs be monitored to ensure access to medically necessary care by all patients in the ACO? 2. How should ACOs be monitored to ensure that its providers do not discriminate against patients on the basis of health or social status and ensure against selectionbias of healthy or low-cost patients? Accountable Care Organizations RFI 8

13 3. What policies are necessary to ensure against underutilization and overutilization of services? 4. How should engagement of patients and clinicians in the transition to becoming an ACO be monitored and documented? 5. What types of personnel and services could be utilized to ensure access for patients whose social, economic or health-related conditions create barriers? K. Supplementary Services Certain services that are not part of the minimum set of services an ACO must provide or coordinate as set forth in the definition of Integrated Health Care Services are nonetheless important health care services and supports that are needed by health care consumers. (Please see Section III.A.3 for additional questions regarding this definition.) For example, EOHHS contemplates that some ACOs may decide to provide or coordinate short-term and long-term facility-based services as well as community based long-term services and supports. EOHHS seeks input on how these services and supports can be provided for in a transition to a new model of care using ACOs. 1. How can the state best promote ACO formation as well as other needed services and programs, including but not limited to medical education, stand-by and emergency services, services provided by safety net hospitals or other providers serving underserved populations, research, care coordination and community-based long-term services and supports? 2. What challenges are there to providing short-term and long-term facility-based services as well as community-based long term services and supports through an ACO, or in the context of ACO formation? How can ACOs be structured and organized to promote more coordinated care for patients who need these services and supports? 3. What challenges are there to providing behavioral health care services through an ACO, or in the context of ACO formation? How can ACOs be structured and organized to promote more coordinated care for patients receiving behavioral health care services? 4. Are there categories or types of Integrated Health Care Services, or any other services and supports, which may be particularly difficult to coordinate or provide through an ACO? If so, what are they, and why? What new approaches to care delivery or organization and management may be needed to address these challenges? What services are best paid for pursuant to a fee-for-service model? 5. Providers that sometimes are categorized outside of the traditional categories of medical or mental health (e.g., dental, chiropractic, midwifery and homeopathic) Accountable Care Organizations RFI 9

14 may have specific questions about their involvement in an ACO. What issues will ACOs have around the services delivered by these providers? 6. Providers have sometimes employed community health workers, patient navigators and non-clinical staff to assist in overcoming access barriers, supporting prevention and/or promoting patient-centered chronic disease management. How, and under what circumstances, could or should such staff be utilized by ACOs? L. Populations with Complex Needs 1. How can ACOs form to best meet the needs of MassHealth members, given the health status of the diverse member population? How could ACOs best serve members with complex needs? 2. Are there specific populations or types of care that may be particularly suited, or not suited, to receiving care through an ACO? Which ones, and why or why not? 3. Please describe any specialized staff or services that are needed to address the particular health needs of members with complex health needs. Please describe any particular linkages that ACOs should have to community-wide activities to promote health. M. State Contracting with MCOs State government health care purchasing may help to accelerate the transformation to less costly and higher quality health care systems by utilizing ACOs and alternative payment methods for the delivery of publicly-funded health services under competitive procurement processes. 1. What policies should be adopted to encourage organizations to form ACOs to provide and coordinate publicly-funded health services? 2. What policies should be adopted to promote both competition in the health care market to provide services to publicly insured individuals as well as a transition to the use of ACOs for the provision of such services? 3. What pilots, demonstrations, or other programs should the state consider to promote integrated, high quality care through ACOs for publicly insured individuals? How can such programs be designed and implemented so that they may ultimately be more broadly adopted throughout the health care industry in the Commonwealth? N. Proposed Federal ACO Regulations On April 7, 2011, the federal Centers for Medicare & Medicaid Services and the Office of the Inspector General issued proposed regulations (42 CFR et. seq.) relating to ACOs Accountable Care Organizations RFI 10

15 in connection with the Medicare Shared Savings program of the Patient Protection and Affordable Care Act (section 3022). 1. What aspects of these proposed regulations should be incorporated in state ACO policies? 2. Which aspects of the proposed regulations raise issues for providers seeking to form ACOs? 3. What aspects of the proposed regulations could be beneficial if modified, and what should those modifications be? O. Questions for Health Plans 1. What role should Medicaid managed care organizations (MCOs) have in the transition to use of ACOs for care coordination and delivery? 2. How could Medicaid MCOs and other health plans help transform the health care payment and delivery system? 3. Could Medicaid MCOs become ACOs? How could that transition be made? SECTION IV. RFI Respondent Information Please respond to the following questions: A. In what geographic areas in Massachusetts do you provide services? B. If you provide services, how many people do you serve annually? C. If you provide services, what kinds of direct services do you provide? D. If you do not provide services, what is your role in the health care system? Accountable Care Organizations RFI 11

16 SECTION V. RFI Response Instructions A. Submission Instructions The deadline for receipt of RFI responses is July 13, 2011 (Eastern Time). Responses may be submitted in one of the following ways: By to: or In writing to: B. Format Lisa D. Wong, Procurement Coordinator Executive Office of Health and Human Services One Ashburton Place, 11 th Floor Boston, MA All parties interested in responding to this RFI should use the ACO RFI Response Template, attached hereto as Attachment A, for responding to the questions in Sections III and IV above. The questions in the template are identical to the questions found in Sections III and IV of this RFI. Parties interested in responding to the RFI should prepare an electronically submitted response or a typewritten response to the questions listed in Sections III and IV above, using the ACO RFI Response Template (Attachment A). EOHHS prefers to receive electronic submissions but will also accept typewritten responses. Any typewritten response should be double-sided/single-spaced. Parties responding in hard copy should submit one original and three copies of their response. The first page of the response shall be a cover letter that includes the following information: Respondent s name, organization and address; and Respondent affiliation or interest (health organization, health care provider, community member, professional association/trade group, health care consultant, advocate/advocacy organization, consumer/patient, government organization). Interested Parties are invited to respond to any or all of the RFI questions; please respond to as many as you feel are appropriate. Responses, including the template any attachments thereto, should be clearly labeled and referenced by name in the RFI response documents. The RFI does not obligate EOHHS to issue a Request for Responses (RFR) nor to include any of the RFI provisions or responses in any RFR. No part of the response can be returned. Receipt of RFI responses will not be acknowledged. Accountable Care Organizations RFI 12

17 SECTION VI. Additional RFI Information A. Comm-PASS This RFI has been distributed electronically using the Commonwealth Procurement Access and Solicitation System (Comm-PASS). Comm-PASS is an electronic mechanism used for advertising and distributing the Commonwealth of Massachusetts procurements and related files. No individual or organization may alter (manually or electronically) the RFI or its components except for those portions intended to collect the respondent s response. Interested parties may access Comm-PASS at Questions specific to Comm-PASS should be made to the Comm-PASS Help Desk at commpass@osd.state.ma.us or (888) MA-State ( ). B. RFI Amendments Interested parties are solely responsible for checking Comm-PASS for any addenda or modifications that are subsequently made to this RFI. The Commonwealth and its subdivisions accept no liability and will provide no accommodation to interested parties who fail to check for amended RFIs. C. Use of RFI Information Information received in response to this RFI shall serve solely to assist the Commonwealth in the development of policy. No information received in response to this RFI is binding on the Commonwealth or any of its agencies. Responding to this RFI is entirely voluntary and will in no way affect consideration of any proposal submitted in response to any subsequent procurement or solicitation. Responses to this RFI become the property of the Commonwealth of Massachusetts and are public records under the Massachusetts Freedom of Information Law, M.G.L.c.66, section 10 and c.4, section 7, clause 26, regarding public access to such documents. However, information provided in its response to this RFI and identified by the respondent as trade secrets or commercial or financial information shall be kept confidential to the extent permitted by law and shall be considered by EOHHS as exempt from disclosure as a public record (see Massachusetts General Laws, Chapter 4, section 7(26) g. This exemption may not apply to information submitted in response to any subsequent procurement solicitations. Accountable Care Organizations RFI 13

18 ATTACHMENT A ACO RFI RESPONSE TEMPLATE Accountable Care Organizations RFI

19 ATTACHMENT A ACO RFI RESPONSE TEMPLATE Please use this template to respond to the questions contained in the RFI. The questions in the template are identical to the questions found in Sections III and IV of the RFI. Interested parties are invited to respond to any or all of the questions; please respond to as many as you feel are appropriate. SECTION III.A. Definitions; ACO Structure and Services 1. How will providers form ACOs in a manner that complies with the above definitional requirements? 2. What issues are raised by the above definition that may interfere with or otherwise affect ACO formation? 3. The definition of Integrated Health Care Services as set forth in Section II does not include all Medicaid covered services. Should this definition be expanded to include additional, or all, Medicaid covered services? As a related matter, should an ACO that contracts with the state Medicaid agency include (and be able to satisfy all ACO requirements indicated in Section II. above for) additional, or all, Medicaid covered services, including dental, long term care services and supports, and other Medicaid covered services? 4. Should knowledge of and capacity to refer to and support community-based services and activities that promote or encourage wellness be included as part of the required core ACO capacities? SECTION III.B. Stakeholder Collaboration 1. How might the state, providers, patients and consumer groups, payers, and other health care stakeholders work together to promote the formation of ACOs and the ongoing adoption of the ACO delivery model as a mechanism to improve quality and coordination of care? Accountable Care Organizations RFI 1

20 2. How should EOHHS and other state health purchasing agencies market and communicate the nature of the transition to ACOs to publicly insured individuals? 3. How will the transition to the use of ACOs affect the relationship between payers and providers? What new arrangements between payers and providers may arise as a result of this transition? 4. How can meaningful partnerships be built between ACOs and non-clinical community services and neighborhood-based agencies to promote healthier conditions in patients lives? SECTION III.C. ACO Formation 1. How could EOHHS and other state health purchasing agencies encourage ACO formation? 2. What potential challenges do the definitional requirements set forth in Section II above pose for providers interested in forming an ACO? How can those challenges be addressed? 3. What steps are needed for multiple providers operating as Patient-Centered Medical Homes to become an ACO? How can primary care remain at the core of the organizational structure, as providers form more integrated organizations and arrangements? 4. What types of incentives would best promote ACO formation? Other than financial incentives, are there specific items that would, if established, operate to encourage healthcare providers to form ACOs? Accountable Care Organizations RFI 2

21 5. How should ACOs demonstrate that they have the clinical coordination, population management functions, financial and contract management capabilities, quality measurement competence, patient and provider communications functions, and the ability to provide specialty services, including behavioral health services that are needed to operate as an ACO? 6. What policies could EOHHS consider that might help small and individual practitioners to participate in ACOs? 7. How should ACOs ensure that their policies and decision-making processes promote the best health outcomes for the patients they serve? 8. In addition to core clinical staff and services, should other types of employees and/or services be utilized to assist in preventing illness and injury and promoting good health? If so, what other types of employees and/or services would be needed? 9. What structural, organizational, clinical, financial, legal, geographic, or other issues may pose barriers to ACO formation? 10. Are there geographic or regional differences in readiness to transition to an ACO? If so, what can be done to address these barriers? 11. What should the method be for assigning or attributing individuals to an ACO? Accountable Care Organizations RFI 3

22 SECTION III.D. Transition Period There may be a transition period as health care providers form or join more integrated organizations. The following questions address issues that may arise during the transition to ACO formation. 1. What types of transitional programs (e.g. system delivery pilots, interim alternative payment programs) would be most helpful to encourage and support ACO formation and success during this period? 2. Certain healthcare providers may require technical and infrastructure development processes to transition into ACOs. a. Please describe any areas of technical and infrastructure development processes providers will need to make this transition. b. What specific assistance may be needed to help providers that want to participate in an ACO be able to do so? c. Are there types of assistance other than financial help that will be useful to providers? d. What types of assistance will providers need to be able to measure, track, report on, and meet identified quality and performance measures? 3. What are the anticipated costs of transformation to an ACO? Accountable Care Organizations RFI 4

23 SECTION III.E. ACO Organization and Governance 1. What parameters, if any, should be established regarding ACO organization and governance? 2. What kinds of structures are needed to ensure appropriate integration, coordination, and quality of care for patients in an ACO? 3. How should ACOs include consumer representation in their organizational governance? What consumer protections are needed in the transition to ACOs, and how should they be implemented? What mechanisms to ensure consumer engagement should be established? 4. How should ACOs ensure that their decision-making reflects the views of its network providers? SECTION III.F. Care Coordination; Performance Measures 1. How can ACOs demonstrate improved coordination of care delivery? 2. Payments to ACOs may be based at least in part on achievement of measures of performance and outcomes. This could be measured in a number of ways, including but not limited to demonstrating improved access to care, quality of care and outcomes, and patient satisfaction. What quality and other measures should be considered as part of performance? How should they be established? 3. How should EOHHS assess patient and provider experience as a measurement of ACO performance? Accountable Care Organizations RFI 5

24 4. Since the primary goal of the ACO is to promote good health through improving the quality and coordination of care delivered, how might ACOs be incentivized to improve both the quality and coordination of care delivered by the ACO? 5. Are there particular measures that would capture health promotional or disease prevention efforts both in traditional and non-traditional settings and with multi-disciplinary staff? SECTION III.G. Data Collection and Publication EOHHS and the other state health purchasing agencies would need evidence to support the effectiveness of ACOs and payment reform, and would need to carefully document metrics and outcomes. Data reporting must be timely to meet these requirements. Encounter level data and other reports would be required for all encounters (e.g., administrative, financial, and quality reports), including those provided by subcontractors and ACO network providers (providers that by contract or corporate structure participate in a specific ACO). 1. EOHHS seeks to improve the collection and transparency of data relating to both the quality and cost of care. What would be the optimal means of collecting, analyzing, and publishing data regarding the achievement of quality measures, disease prevention and health promotion, patient satisfaction, cost, payments by providers and payers, and other relevant information? 2. What data should the ACO be required to submit to the payer? How could ACOs and providers partner with payers to create streamlined data collection and reporting processes? a. Please comment on any issues that may be a barrier to complying with data requirements and strategies to address potential barriers. b. What potential health information technology, data, and/or reporting infrastructure needs may have to be addressed in support of ACO operations and patient care coordination? c. Would a provider need any data other than its own in order to form and operate as an ACO? How could privacy issues be addressed? Please include specifics about any data exchanges that would need to be established. Accountable Care Organizations RFI 6

25 3. What is the minimum necessary data providers would need to prepare a response to a procurement soliciting bids for ACOs to contract with the state to provide health care services for publicly insured individuals? 4. What financial information would be helpful when preparing a response to such a procurement? SECTION III.H. Payment/Savings and Financial Administration ACOs may need to be prepared to accept Alternative Payment Methodologies, as defined in Section II. EOHHS plans to utilize contracting mechanisms that reward high-quality performance and health outcomes. 1. What services should be included in risk based reimbursement? Please explain if any services should not be reimbursed on a risk basis, and why. 2. How will these Alternative Payment Methodologies affect the way in which ACOs are formed? 3. What kinds of financial arrangements should be used to compensate ACO network providers? Please propose options as to how the money would flow from the ACO to the ACO network providers. 4. How should the ACO track spending for patients served by ACOs when they receive care outside of the network? Accountable Care Organizations RFI 7

26 5. How should the costs of care for patients that go out of the ACO for care be handled? What incentives should the ACO consider to keep patients from going outside the ACO for care? 6. What key challenges might ACOs face in administering alternative forms of payment, including reimbursement to individual ACO providers where bundled or global payments are made to the ACO? How can ACOs ensure new payment methodologies meet the needs of ACO network providers? 7. In the long term how do you envision payment trends changing? SECTION III.I. ACO Risk EOHHS envisions that ACOs could take on several levels of risk. The first level is financial risk based on performance, where providers forgo payment if certain clinical performance criteria are not met. The second (and higher) level is insurance risk, where ACOs assume full risk for all care for patients. 1. What criteria should be used to evaluate the ability of an ACO to take on financial risk? What controls are necessary to ensure that ACOs do not take on excess risk but are encouraged to take on appropriate performance risk? 2. What policies are needed to ensure that ACOs do not incur excessive costs due to catastrophic or other expensive, unforeseen patient care? Accountable Care Organizations RFI 8

27 3. EOHHS anticipates that payments to ACOs will be risk adjusted to help protect ACOs from excess financial harm due to high cost patients or other factors. What types of risk adjusters should be used to adjust global and other alternative payment methods, to help protect ACOs from taking on excess risk? 4. Should ACOs be required to have a minimum number of beneficiaries? 5. Should ACOs/providers contract directly with MassHealth and other state health purchasing agencies to deliver integrated care? What policies and procedures are necessary to facilitate this strategy? SECTION III.J. Access 1. How should ACOs be monitored to ensure access to medically necessary care by all patients in the ACO? 2. How should ACOs be monitored to ensure that its providers do not discriminate against patients on the basis of health or social status and ensure against selection-bias of healthy or low-cost patients? 3. What policies are necessary to ensure against underutilization and overutilization of services? 4. How should engagement of patients and clinicians in the transition to becoming an ACO be monitored and documented? Accountable Care Organizations RFI 9

28 5. What types of personnel and services could be utilized to ensure access for patients whose social, economic or health-related conditions create barriers? SECTION III.K. Supplementary Services Certain services that are not part of the minimum set of services an ACO must provide or coordinate as set forth in the definition of Integrated Health Care Services are nonetheless important health care services and supports that are needed by health care consumers. (Please see Section III.A.3 for additional questions regarding this definition.) For example, EOHHS contemplates that some ACOs may decide to provide or coordinate shortterm and long-term facility-based services as well as community based long-term services and supports. EOHHS seeks input on how these services and supports can be provided for in a transition to a new model of care using ACOs. 1. How can the state best promote ACO formation as well as other needed services and programs, including but not limited to medical education, stand-by and emergency services, services provided by safety net hospitals or other providers serving underserved populations, research, care coordination and community-based long-term services and supports? 2. What challenges are there to providing short-term and long-term facility-based services as well as community-based long term services and supports through an ACO, or in the context of ACO formation? How can ACOs be structured and organized to promote more coordinated care for patients who need these services and supports? 3. What challenges are there to providing behavioral health care services through an ACO, or in the context of ACO formation? How can ACOs be structured and organized to promote more coordinated care for patients receiving behavioral health care services? 4. Are there categories or types of Integrated Health Care Services, or any other services and supports, which may be particularly difficult to coordinate or provide through an ACO? If so, what are they, and why? What new approaches to care delivery or organization and management may be needed to address these challenges? What services are best paid for pursuant to a fee-for-service model? Accountable Care Organizations RFI 10

29 5. Providers that sometimes are categorized outside of the traditional categories of medical or mental health (e.g., dental, chiropractic, midwifery and homeopathic) may have specific questions about their involvement in an ACO. What issues will ACOs have around the services delivered by these providers? 6. Providers have sometimes employed community health workers, patient navigators and non-clinical staff to assist in overcoming access barriers, supporting prevention and/or promoting patientcentered chronic disease management. How, and under what circumstances, could or should such staff be utilized by ACOs? SECTION III.L. Populations with Complex Needs 1. How can ACOs form to best meet the needs of MassHealth members, given the health status of the diverse member population? How could ACOs best serve members with complex needs? 2. Are there specific populations or types of care that may be particularly suited, or not suited, to receiving care through an ACO? Which ones, and why or why not? 3. Please describe any specialized staff or services that are needed to address the particular health needs of members with complex health needs. Please describe any particular linkages that ACOs should have to community-wide activities to promote health. Accountable Care Organizations RFI 11