Summary of Arrangements Conducted under the Medicare ACO Participation Waiver

Transcription

1 Summary f Arrangements Cnducted under the Medicare ACO Participatin Waiver Last Updated: January 1, EHR Subsidy Arrangements ( ). Effective August 14, 2013, the Jhn Muir Physician Netwrk (JMPN) dba Jhn Muir Health Medicare Accuntable Care Organizatin (the ACO) apprved an arrangement (EHR Subsidy Arrangement) under the ACO Participatin Waiver pursuant t which JMPN will prvide r arrange fr the prvisin f certain EHR Sftware and Supprt Services t varius Eligible Practices at discunted rates. The EHR Subsidy Arrangement, as apprved by the ACO, includes a frm f EHR Sftware and Supprt Services Agreement (EHR Subsidy Agreement). The parties t each EHR Subsidy Arrangement will be Jhn Muir Health (JMH) and the ACO, n the ne hand, and the Eligible Practice, n the ther hand. EHR Sftware and Supprt Services will include an integrated EHR suite (cre EHR, patient registratin/scheduling functinality, and practice management/billing functinality), as well as related training and supprt services. Eligible Practices include ACO Participants and ACO Affiliated Practices. ACO Participants are individuals r entities that have entered int a Participatin Agreement t participate in the ACO as ACO Participants (as defined under the MSSP). ACO Affiliated Practices are individuals r entities that emply r cntract with physicians practicing in ne f the Select Specialties, and which have entered int a Care Crdinatin Agreement with the ACO under which they cmmit t substantially similar care crdinatin and citizenship requirements as ACO Participants, but withut participating as ACO Participants. Select Specialties include 13 specialties that the ACO has identified as critical t managing its ACO Beneficiary ppulatin, either n the basis f the Specialty s relative cntributin t the ACO s benchmark Medicare Part A/B fee fr service claims/encunters, r n the basis f the Specialty s ability t effectively manage r mitigate the ACO s Medicare Part A/B feefr service claims experience. The EHR Subsidy Arrangement is intended t facilitate the widespread adptin f EHR technlgy by healthcare prviders prviding medical care and treatment t individuals residing in the cmmunities served by the ACO (Service Area) in rder t enhance and imprve the efficiency, effectiveness, quality and clinical integratin f care prvided t such individuals. The EHR Subsidy Arrangement therwise is structured t cmply with the exceptin fr dnatin f EHR sftware and services at 42 C.F.R (w) (EHR Dnatin Exceptin) and the related safe harbr at 42 C.F.R (y) (EHR Dnatin Safe Harbr). Hwever, the subsidy levels under the EHR Subsidy Page 1 f 8

2 Arrangement are higher than thse permitted under the EHR Dnatin Exceptin and the EHR Dnatin Safe Harbr. Accrdingly, the EHR Subsidy Arrangement must cmply with an applicable MSSP waiver. The EHR Subsidy Arrangement has tw cmpnents an up frnt, ne time implementatin cmpnent and an nging mnthly maintenance and supprt cmpnent. Fr each cmpnent, Eligible Practices will pay JMPN a specified amunt per Authrized User that crrespnds t a percentage f JMPN s actual aggregate cst f prviding r arranging fr the prvisin f the EHR Sftware and Supprt Services (Practice Payments). Authrized Users include physicians and mid level practitiners (i.e., nurse practitiners and physician assistants). Mid level practitiners and part time physicians are eligible fr additinal discunts ff the base Authrized User rate. JMPN may review and adjust Practice Payments n an annual basis t ensure that each Eligible Practice pays a minimum percentage f JMPN s actual aggregate cst t prvide r arrange fr the prvisin f the EHR Sftware and Supprt Services. If an Eligible Practice underges a change in cntrl (as defined in the EHR Subsidy Agreement) within a defined time perid fllwing the effective date f its EHR Subsidy Agreement (Effective Date), then, unless agreed in writing by JMPN, fr each f the Eligible Practice s Authrized Users frm the Effective Date thrugh the effective date f the change in cntrl, the Eligible Practice will we JMPN certain default fees. The default fees equal the difference between the subsidized rate the Eligible Practice received fr the ne time implementatin cmpnent and JMPN s actual csts (i.e., t make JMPN whle fr its implementatin csts fr thse Authrized Users). If an Eligible Practice wants t add an Authrized User wh renders prfessinal services at lcatins utside f the Service Area, r if an existing Authrized User begins t render prfessinal services at lcatins utside f the Service Area (Out f Area Practitiner), the Eligible Practice will ntify JMPN and discuss the request. JMPN has discretin t determine: (a) whether such Out f Area Practitiner may becme r remain, as applicable, an Authrized User, and (b) the amunt f the Practice Payments that the Eligible Practice will pay ging frward with respect t the Out f Area Practitiner. Mdified Practice Payments fr Out f Area Practitiners may be higher than the Practice Payments fr ther Authrized Users, and any mdified Practice Payments will be set frth in a written amendment t the Eligible Practice s EHR Subsidy Agreement. JMPN will have the right t audit an Eligible Practice s bks and recrds t validate ptential Outf Area Practitiners. Each EHR Subsidy Agreement has an initial term that is cterminus with the ACO s MSSP Participatin Agreement with CMS, with specified renewal ptins upn mutual agreement f the parties. Page 2 f 8

3 Each party can terminate fr cause and certain ther reasns specified in the EHR Subsidy Agreement (e.g., expiratin r terminatin f the ACO s MSSP Participatin Agreement; expiratin r terminatin f an Eligible Practice s Participatin Agreement r Care Crdinatin Agreement with the ACO). 2. Care Crdinatin Payments (2015) 2015 Care Crdinatin Fee. Effective January 1, 2015, the ACO apprved a prspective update t the Perfrmance Criteria under the ACO Participatin Waiver fr the perid 01/01/15 12/31/15. See Care Crdinatin Payments (2014) belw fr descriptins f the mst recent set f Perfrmance Criteria and Care Crdinatin Payments. The updated Perfrmance Criteria reduce the ttal number f measures t better fcus Participants effrts n activities the ACO believes will further its achievement f the Triple Aim, refine certain measurement threshlds, and extend the measurement perid t a full calendar year. Specifically: Criteria #1 (annual Medicare wellness visit) and Criteria #2 (PCP fllw up fllwing hspital discharge) are remved. Criteria #3 (care plan engagement) is updated t increase the relative pint value f this measure. Criteria #4 (mnthly care crdinatin team meetings) is retained. New criteria added (ACO Cngress attendance), requiring each f an ACO Participant s PCP Prfessinals t attend at least tw JMH Medicare ACO Cngress sessins during the 2015 calendar year, except as therwise apprved in advance by the ACO C Chairs and ACO Medical Directr. New criteria validated based n attendance sheets at ACO Cngress sessins (sign in and sign ut). The financial penalty fr each ACO Prfessinal wh fails t attend an ACO Cngress sessin is remved. The measurement perid fr the Care Crdinatin Payments is extended t include full calendar year 2015, rather than a 6 mnth perid. The ACO s gverning bdy retained the certificatin, validatin, and payment prcess utlined belw fr the 2014 Care Crdinatin Payments. As with the 2014 Care Crdinatin Payments, the ACO s gverning bdy reviewed and apprved distributin f a frm f ntice cntaining the relevant details f the restructuring, t be distributed t each Participant befre Nvember 30, The parties cvered under the Care Crdinatin Payment arrangements summarized abve include Participants wh were Participants in the ACO as f the end f the applicable twelve mnth perfrmance perid. 3. Care Crdinatin Payments (2014) Secnd Half 2014 Care Crdinatin Fee. Effective July 1, 2014, the ACO apprved a prspective update t the Perfrmance Criteria under the ACO Participatin Waiver fr the perid 07/01/14 12/31/14. See First Half Page 3 f 8

4 2014 Care Crdinatin Fee belw fr descriptins f the mst recent set f Perfrmance Criteria and Care Crdinatin Payments. The updated Perfrmance Criteria make tw sets f mdificatins t better fcus Participants effrts n activities the ACO believes will further its achievement f the Triple Aim. Specifically: Criteria #4 (mnthly meetings with Care Crdinatrs) is updated t: (1) prvide that the Care Crdinatin Team will measure and reprt the results based upn the methdlgy apprved by the ACO Executive Cmmittee; and (2) change the measurement threshld frm a sliding scale that required 5 meetings t achieve full credit, t an all r nthing scale that requires at least 3 meetings t achieve full credit. The Care Crdinatin Fee payable t a Participant fr the secnd half f 2014 will have a set amunt withheld fr each f that Participant s PCP Prfessinals wh d nt attend at least ne JMH Medicare ACO educatin sessin befre 12/31/2014. The ACO s gverning bdy retained the certificatin, validatin, and payment prcess utlined belw fr the 2013 Care Crdinatin Payments. As with the 2013 Care Crdinatin Payments, the ACO s gverning bdy reviewed and apprved distributin f a frm f ntice cntaining the relevant details f the restructuring, t be distributed t each Participant befre May 31, The parties cvered under the Care Crdinatin Payment arrangements summarized abve include Participants wh were Participants in the ACO as f the end f the applicable six mnth perfrmance perid. First Half 2014 Care Crdinatin Fee. Effective January 1, 2014, the ACO apprved a prspective update t the Perfrmance Criteria under the ACO Participatin Waiver fr the perid 01/01/14 06/30/14. See Care Crdinatin Payments ( ) belw fr descriptins f the mst recent set f Perfrmance Criteria and Care Crdinatin Payments. The updated Perfrmance Criteria reduce the ttal number f measures t better fcus Participants effrts n activities the ACO believes will further its achievement f the Triple Aim, and refine certain measurement threshlds. Specifically: Criteria #1 (annual wellness visits) is updated t increase the relative pint value f this measure (frm 20 t 30 pints), eliminate the ability fr Participants t self reprt billing data, and increase the measurement threshld that Participants must meet t receive credit fr this measure. Criteria #2 (pst discharge PCP appintment) is updated t increase the relative pint value f this measure (frm 20 t 30 pints), extend the appintment windw t 14 days f discharge frm a Jhn Muir Health hspital (frm 7 days), eliminate the reference t discharges frm affiliate hspitals, and eliminate the reference t discharges where the patient s assigned PCP is als the discharging physician. Criteria #3 (PCP fllw up visit after ED r urgent care encunter) is eliminated. Criteria #4 (ACO Cngress/training attendance by PCPs) is eliminated. Page 4 f 8

5 Criteria #5 (PCP engagement in develpment f care plan) is updated t reflect PCP participatin in develpment f the care plan fr ACO Beneficiaries assigned t the ACO s care management team (per the ACO s care management guidelines). Renumbered t Criteria #3. Criteria #6 (PCP respnsiveness t care managers) is updated t reflect PCP participatin in either in persn r telephnic mnthly meetings with a member f the Care Crdinatin Team t review at risk ACO Beneficiaries and discuss plans f care. Pint value increased (frm 10 t 30 pints). Renumbered t Criteria #4. Criteria #7 (ACO training/educatin sessin attendance by ffice managers) is eliminated. The Care Crdinatin Fee payable t a Participant fr the first half f 2014 will have a set amunt withheld fr each f that Participant s PCP Prfessinals wh d nt attend at least ne JMH Medicare ACO educatin sessin befre June 30, The ACO s gverning bdy retained the certificatin, validatin, and payment prcess utlined belw fr the 2013 Care Crdinatin Payments. As with the 2013 Care Crdinatin Payments, the ACO s gverning bdy reviewed and apprved distributin f a frm f ntice cntaining the relevant details f the restructuring, t be distributed t each Participant befre Nvember 30, The parties cvered under the Care Crdinatin Payment arrangements summarized abve include Participants wh were Participants in the ACO as f the end f the applicable six mnth perfrmance perid. 4. Care Crdinatin Payments ( ). Effective January 24, 2013, the Jhn Muir Physician Netwrk dba Jhn Muir Health Medicare Accuntable Care Organizatin (the ACO) apprved tw related arrangements under the ACO Participatin Waiver that restructure certain care crdinatin incentive payments (Care Crdinatin Payments) payable by the ACO t its ACO Participants (cllectively, Participants). The first arrangement restructures Care Crdinatin Payments fr the perid 07/01/12 12/31/12. The secnd arrangement restructures Care Crdinatin Payments fr the perid 01/01/13 06/30/13. Neither arrangement changes the maximum amunts ptentially payable in Care Crdinatin Payments. Rather, these arrangements (a) adjust the perfrmance criteria Participants must meet t qualify fr the Care Crdinatin Payments (the Perfrmance Criteria), and (b) refine the calculatin and payment methdlgy fr the Care Crdinatin Payments t mre apprpriately reflect the parties riginal intent. The riginal participatin agreements between the ACO and its Participants prvided fr a Care Crdinatin Payment, calculated n a per member per mnth (PMPM) basis, payable nce every 6 mnths t each Participant based n the number f Medicare fee fr service (FFS) beneficiaries assigned t the Participant's primary care physicians (PCPs). The Care Crdinatin Payments were t be paid based n the number f Medicare FFS beneficiaries assigned t the Participant s PCP s as f the end f the 6 mnth perfrmance perid. Payment f the Care Crdinatin Payment was cntingent n the Participant (and each f such Participant's PCPs) meeting certain Perfrmance Criteria, as defined in the participatin agreement. The initial Perfrmance Criteria required, amng ther things, that Participants (and each PCP under such Participant s TIN) implement r agree t implement an apprved electrnic health recrd system by December 31, 2012; agree t participate in data integratin initiatives; cllabrate and fully engage in ACO care Page 5 f 8

6 management prgrams; electrnically submit data by June 30, 2013 fr all applicable Quality Standards metrics and Meaningful Use data, and share all clinical data fr care management and quality purpses, as requested by bth CMS and the ACO; participate in at least 75% f ACO educatinal sessins annually; perfrm and dcument annual ffice visits with at least 80% f CMS beneficiaries assigned t physician's practice; and demnstrate engaged use f the McKessn MedVentive sftware. Varius issues with the Perfrmance Criteria led t the need fr restructuring: Amng ther issues, the Perfrmance Criteria were riginally and inadvertently drafted in an "all r nthing" fashin. i.e., if the terms and cnditins f the participatin agreements were interpreted and enfrced literally, then if ne PCP f ne Participant failed t meet any f the numerus Perfrmance Criteria, the Participant wuld receive $0 in Care Crdinatin Payments. This utcme wuld have been incnsistent with the parties' riginal intent t prvide a scaled Care Crdinatin Payment based n a Participant's PCPs perfrmance relative t the Perfrmance Criteria. The Perfrmance Criteria were develped mnths befre the ACO realized there wuld be significant delays in btaining beneficiary data frm CMS, which materially limited what activities the ACO wuld be able t measure. In additin, since the initial criteria were develped, the ACO identified different activities that were als imprtant t its gals but which were nt reflected in the riginal Perfrmance Criteria. As a result, if the participatin agreements were strictly enfrced as written, n Care Crdinatin Payments wuld have been made fr 2012 r fr the first mnth f This utcme wuld have frustrated the intent f the ACO s riginal agreement with its Participants, all f whm had dedicated time, persnnel, and resurces t carrying ut varius activities at the request f the ACO in furtherance f the ACO's care crdinatin gals. In light f these circumstances, the ACO restructured the Care Crdinatin Payments fr 2012 and the first half f 2013 as fllws: Fr the perid 07/01/12 12/31/12, the ACO's gverning bdy reviewed and apprved a revised set f Perfrmance Criteria that mre accurately reflected the nature f the care crdinatin activities the ACO had requested its Participants t perfrm. The revised Perfrmance Criteria fr 2012 were substantially similar t the riginal Perfrmance Criteria, but in place f sme f the riginal criteria, substituted requirements related t lgging in t the accunt t which cmmunicatins frm the ACO wuld be sent; implementing the standardized ACO template materials at applicable practice lcatins; and revising the ffice visit percentage threshld t mre apprpriately reflect a partial year perfrmance perid. The Perfrmance Criteria were restructured n a sliding scale basis t prvide partial credit if Participant s PCPs met sme, but nt all, f the Perfrmance Criteria. Each f the Perfrmance Criteria was assigned an equal weight (i.e., 7 pints ttal pssible fr each PCP). Fr Participants with multiple PCPs under ne TIN (e.g., PCPs participating in a grup practice), the sliding scale wuld be applied first t each PCP practicing under the applicable TIN, and then aggregated t determine the ttal percentage f the Care Crdinatin Payment fr which the Participant wuld be eligible. That ttal percentage wuld be applied t the PMPM Care Crdinatin Payment, and then multiplied by the ttal number f Medicare FFS beneficiaries Page 6 f 8

7 assigned t that Participant s PCPs t determine the ttal Care Crdinatin Payment payable t such Participant. Fr Participants participating n an individual basis, the sliding scale wuld be calculated with respect t each such individual PCP. In rder fr a Participant t qualify fr the restructured Care Crdinatin Payment, ACO management wuld distribute a frm f certificatin. Each Participant wuld be respnsible fr verifying the perfrmance f its PCPs against the revised Perfrmance Criteria and returning the certificatin t the ACO Chief Executive r her designee within 30 days f the date f mailing. Once the perid fr receiving certificatins has clsed, the ACO Chief Executive r designee wuld validate the respnses and calculate and pay the Care Crdinatin Payment, if any, wed t each Participant within 30 days. The restructured Care Crdinatin Payment wuld be subject t a withhld by the ACO, t reserve against ptential reductins in Medicare FFS beneficiaries assigned t the Participant s PCPs as f the end f the applicable perfrmance year (here, 12/31/13). At the end f the perfrmance year, the ttal Care Crdinatin Payments paid t each Participant wuld be recnciled against the Medicare FFS beneficiaries assigned t such Participant as f the end f the perfrmance year, with any resulting difference being paid by r t the ACO, as applicable. Fr the perid 01/01/13 06/30/13, the ACO's gverning bdy reviewed and apprved a further revised set f Perfrmance Criteria that mre accurately reflected the nature f the care crdinatin activities the ACO had requested its Participants t perfrm. The further revised Perfrmance Criteria cver seven categries wrth a ttal f 100 pints: (1) PCP s practice perfrms and dcuments an annual Medicare wellness visit with his/her assigned ACO Beneficiary (20 pints); (2) ACO Beneficiary receives an appintment t see his/her assigned PCP s practice within 7 days f discharge frm a Jhn Muir Health hspital r affiliate hspital, r within 14 days f discharge where his/her assigned PCP is als the discharging physician (20 pints); (3) Fllwing an ED r Urgent Care encunter, fllw up visit appintment with the ACO Beneficiary s assigned PCP s ffice is available within the timeframe requested by the Care Crdinatr (15 pints); (4) each f Participant s PCPs attends at least ne ACO training sessin befre 06/30/13 (15 pints); (5) PCP reviews and signs ff n ACO Beneficiary s Care Plan (10 pints); (6) PCP returns phne call/ frm Care Crdinatr within 2 business days (10 pints); and (7) each f Participant s PCPs attends at least ne Risk Adjustment Frm training sessin befre 06/30/13 (10 pints). The ACO s gverning bdy retained the certificatin, validatin, and payment prcess utlined abve under the restructured 2012 Care Crdinatin Payments. T implement the restructured Care Crdinatin Payments fr the first half f 2013, the ACO s gverning bdy reviewed and apprved distributin f a frm f ntice cntaining the relevant details f the restructuring, t be distributed t each Participant befre January 31, In additin t the Care Crdinatin Fee restructuring utlined abve, effective July 1, 2013, the ACO apprved a prspective update t the Perfrmance Criteria under the ACO Participatin Waiver fr the perid 07/01/13 12/31/13. Page 7 f 8

8 The updated Perfrmance Criteria: (a) expand the universe f CPT cdes that qualify fr Perfrmance Criteria #1 (annual wellness visits) t include new transitinal care management visit cdes; (b) resets Perfrmance Criteria #4 t apply t the secnd half f 2013; and (c) mdifies Perfrmance Criteria #7 t prvide that each f Participant s ffice managers attends at least ne Medicare ACO training/educatin sessin befre 12/31/13. In additin, fr Perfrmance Criteria #1, the ACO will accept self reprted billing data frm Participants t make the initial payment calculatin, with subsequent validatin f thse selfreprted data against claims data CMS prvides the ACO fr ACO Beneficiaries. This change addresses the rughly 120 day delay between the end f a calendar quarter and the ACO s ability t validate CMS claims data (i.e., a 90 day delay fr CMS t prvide the quarterly claims data, and an additinal 30 days fr the ACO t analyze the data fr validatin purpses). This update enables the ACO t make Care Crdinatin Payments within a reasnable time fllwing the clse f the six mnth perfrmance perid. Hwever, the ACO will validate self reprted data against the CMS claims data and will cnduct any necessary recnciliatin against the withhld amunt utlined abve. The ACO s gverning bdy retained the certificatin, validatin, and payment prcess utlined abve fr the first half 2013 Care Crdinatin Payments. As with the first half 2013 Care Crdinatin Payment, the ACO s gverning bdy reviewed and apprved distributin f a frm f ntice cntaining the relevant details f the restructuring, t be distributed t each Participant befre May 31, The parties cvered under the Care Crdinatin Payment arrangements summarized abve include Participants wh were Participants in the ACO as f the end f the applicable six mnth perfrmance perid. * * * With respect t each f the arrangements abve, the ACO s gverning bdy has made and duly authrized a bna fide determinatin, cnsistent with the gverning bdy members duty under 42 C.F.R (b)(3), that the arrangement is reasnably related t the purpses f the Medicare Shared Savings Prgram. Page 8 f 8