Mount Sinai Care: A Medicare Shared Savings Program Primer. Brett Bernstein, MD, AGAF, FASGE Medical Director, Provider Partners of Mount Sinai IPA

Transcription

1 Mount Sinai Care: A Medicare Shared Savings Program Primer Brett Bernstein, MD, AGAF, FASGE Medical Director, Provider Partners of Mount Sinai IPA

2 Mount Sinai Health System Network Mount Sinai Health System Statistics 7 hospital campuses 12 ambulatory surgical centers 10 free-standing ambulatory surgical centers (minority owned) More than 40 clinical and academic relationships with local health care organizations More than 30 affiliations with community health centers Over 3000 physicians in Network 2

3 Provider Partners of Mount Sinai Contracting Activity Payers pay professional fees directly to physicians/groups Contracts with payers Insurer 1 Community and Employed MDs Initiatives Infrastructure Payer Relations Insurer 2 Board Committees Physicians may be eligible for bonus funds based on one or more of the following : a.quality Metrics b.attribution c.citizenship Physicians may be eligible for bonus funds based on participation in one or more of the following : a.shared Savings b.bundles c.pay For Performance

4 Value Based Care -- Potential Economic Gains Linked to Increased Risk and Accountability Capitation Shared- Savings Model: Commercial ACO ormssp Risk Episodic Bundling Hospital- Physician Bundling Gainsharing Accountability Pay for Performance 4

5 Value-Based Payment Transition Timeline Historic Payment Targets Demonstrate Commitment to FFS Alternatives Aggressive Targets for Transition to Risk Percent of Medicare Payments Tied to Risk Models FFS Increasingly Tied to Value Percent of Medicare Payments Tied to Quality 90% 20% 30% 50% 80% 85% Examples of Qualifying Risk Models Adapted from Advisory Board Medicare Shared Savings Program Bundled Payments for Care Improvement Initiative Patient-Centered Medical Home Examples of Quality/ Value Programs Hospital-Acquired Condition Reduction Program Hospital Value-Based Purchasing Program Hospital Readmissions Reduction Program Merit-Based Incentive Payment System The Advisory Board Compa ny advisory.com

6 MACRA- Medicare Access and CHIP Reauthorization Act Codifies Timeline For Shift To Value Based Payment 4 Both Tracks Impose Greater Risk, Strong Incentives for Alternative Models PFS 1 Payment Models Beginning in Merit-Based Incentive Payment System (MIPS) Replaces existing MU, PQRS, and VBM Score based on quality, resource use, clinical improvement, and EHR use Adjustmentsreach -9% / +27% by 2022 MIPS Performance Category Weights For 2021 EHR Use Clinical Improvement 25% 15% 30% 30% Quality Resource Use 2 Alternative Payment Models (APMs) Provides financial incentives (5% annual bonus in ) and exemption from MIPS Requires that physicians meet increased targets for revenue at risk APMs must involve downside risk and quality measurement Source: The Medicare Accessand CHIP Reauthorization Actof 2015; HealthCare Advisory Board interviews and analysis The Advisory Board Compa ny advisory.com

7 CMS Innovative Payment Models Are Evolving 5 Pay-for- Performance Bundled Payments Shared Savings Shared Risk Full Risk Hospital VBP Program Hospital Readmissions Reduction Program HAC Reduction Program Merit-Based Incentive Payment System Bundled Payments for Care Improvement Initiative (BPCI) Comprehensive Care for Joint Replacement Model MSSP Track 1 (potential 50% sharing) Upside Only Track Extended For 3 Years NO RISK MSSP Track 2 (60% sharing) MSSP Track 3 (up to 75% sharing) Next-Generation ACO (80-85% sharing) Next-Generation ACO (optional full performance risk) Medicare Advantage (providersponsored) Increasing Financial Risk Adapted from Advisory Board Source: HealthCare Advisory Board interviews and analysis The Advisory Board Compa ny advisory.com

8 Shared Savings Programs Are Growing in Popularity

9 Mount Sinai Care- A Medicare Shared Savings ACO The Patient Protection & Affordable Care Act (ACA) Became law in March Supreme Court upholds constitutionality of ACA June Authorized creation of Medicare Shared Savings Program (MSSP).

10 Mount Sinai Care- A Medicare Shared Savings ACO What are ACOs? ACOs are physician led organizations through which providers/suppliers participate in the MSSP. A legal entity designed to manage and coordinate care for Medicare fee-for-service beneficiaries under the MSSP. Providers are accountable for cost and quality for a defined population over a specific period of time

11 Mount Sinai Care- A Medicare Shared Savings ACO Required Processes & Patient-Centered Criteria ACO must promote: evidence-based medicine; patient and caregiver engagement; reporting on quality and cost measures; and coordinating care. An ACO must also have a patient-centric focus that is promoted by the governing body and integrated into practice by leadership and management.

12 Mount Sinai Care- A Medicare Shared Savings ACO Assignment of Patient Population ACO accepts responsibility for an assigned Medicare patient population Assignment will not affect beneficiaries Medicare benefits or choice of physician or any other provider Patients are not restricted to specific providers or Patient assignment is prospectively performed based on plurality of claims with retrospective reconciliation.

13 Mount Sinai Care- A Medicare Shared Savings ACO ACO Membership During the application process, CMS evaluates the number of beneficiaries historically assigned to the applicable ACO participants during each of the three years preceding the proposed effective date of the ACO contract. A beneficiary is assigned to an ACO based on that beneficiary s utilization of primary care services by an ACO physician during an MSSP cycle.

14 Mount Sinai Care- A Medicare Shared Savings ACO ACO Payment Overview n n n n ACO participants will continue to be paid FFS rates under the applicable Medicare payment system In addition, ACOs will be eligible to receive shared savings if: ACO meets quality performance standards, and Costs are below a performance target and minimum savings rates ( MSR ) ACO participants will receive most savings Each ACO will decide how to internally share savings among participants 1 4

15 Mount Sinai Care- A Medicare Shared Savings ACO Quality Measurement & Performance Quality measures separated into four domains: 1. Patient/Caregiver Experience 2. Care Coordination/Patient Safety 3. Preventive Health 4. At-Risk Population/Frail Elderly Health ACOs that score higher will be eligible for greater savings Measures aligned with current CMS measurement efforts and incentive programs

16 Mount Sinai Care- A Medicare Shared Savings ACO ACO QUALITY MEASURES Quality Scoring Points System- 33 are pay for performance Quality scoring will be based on the ACO s actual level of performance on each measure. Points are rewarded for both benchmarked performance and improvement. In 2015 ACOs may earn up to 4.00 points in each domain if they demonstrate significant quality improvement.

17 Mount Sinai Care- A Medicare Shared Savings ACO 2015 Quality Measures

18 Mount Sinai Care- A Medicare Shared Savings ACO 2015 Quality Measures

19 Mount Sinai Care- A Medicare Shared Savings ACO Financial Performance Performance year expenditures are calculated and risk adjusted. Account for health status and demographic changes during each performance year Use an ACO s HCC( Hierarchal Categorical Coding) prospective risk score to take into account changes in severity and case mix for beneficiaries who are newly assigned and for beneficiaries who drop out of an ACO s assigned population Use patient demographic factors only to account for changes in the beneficiaries continuously assigned to the ACO s population

20 Why Should I Join Mount Sinai Care?

21 Mount Sinai Care- A Medicare Shared Savings ACO On-ramp for value-based reimbursement By creating an environment for quality assurance and improvement activities, an ACO supports the physicians in developing competencies critical for success under new value-based reimbursement models Learning lab for population health management It is no secret that the key to achieving shared savings is to identify high-cost, high-risk patients and provide them with comprehensive care management services. An ACO s care management infrastructure (including staff, processes, and technology) is foundational to successful population health management.

22 Mount Sinai Care- A Medicare Shared Savings ACO Access to data An MSSP-participating ACO receives from CMS all claims data for the ACO s attributed beneficiaries. Using these data, an ACO can identify opportunities for cost savings as well as quality improvement. The ability to analyze such data effectively will be synonymous with the ability to manage risk.

23 Mount Sinai Care- A Medicare Shared Savings ACO The best defense is a good offense According to a recent analysis*, across the nation 65-70% of the eligible Medicare beneficiary population lives within an assignment area of an MSSP The opportunity to improve data sharing, analytics Moving from understanding gaps in practice to implementing practical solutions to drive improvements that will be sustainable *

24 This presentation is intended to be a summary and not a comprehensive recitation of all applicable rules and regulations. Please refer to the CMS website on the Medicare Shared Savings Program (MSSP) for updated information at: Service- Payment/sharedsavingsprogram/index.html?redirect =/sharedsavingsprogram 24

25 Next Steps Ø Voluntary Primary care providers should receive informational letter and Mount Sinai Care agreement prior to Aug 31, 2015 Ø Signed agreements should be returned by September 8 th

26 Questions???? Theresa Dolan Chief Operating Officer, Mount Sinai Care 26