Accountable Care Organiza2ons: Learnings from other states. Medicaid Working Group Mee2ng Wednesday, June 3, 2015

Transcription

1 Accountable Care Organiza2ons: Learnings from other states Medicaid Working Group Mee2ng Wednesday, June 3, 2015

2 Key Sources Much has been wriqen about ACO development in Medicaid programs ACO Model Comparisons: Experts and Consultants Rhode Island Delivery System Op2ons and Considera2ons presenta2on by Meryl Price, President, Health Policy MaQers A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50- State Survey. Kaiser. September Medicaid Accountable Care Organiza2ons: Program Characteris2cs in Leading- Edge States. CHCS, Feb Paying for Value in Medicaid: A Synthesis of Advanced Payment Models in Four States. Final Report. SHADAC. February The Balancing Act: Integra2ng Medicaid Accountable Care Organiza2ons into a Managed Care Environment. CHCS, November Quality Measurement Approaches of State Medicaid Accountable Care Organiza2on Programs. CHCS, September Minnesota Accountable Health Model: Con2nuum of Accountability Matrix, January 12, Minnesota DHS and Health (MDH). Medicare Medicare Shared Savings Program. Title 42: Public Health PART 425 MEDICARE SHARED SAVINGS PROGRAM Subpart B Shared Savings Program Eligibility Requirements Shared governance. hqp:// tle42- vol3/xml/cfr tle42- vol3- part425.xml#seqnum Medicare Shared Savings Program. Summary of Final Rule Provisions for Accountable Care Organiza2ons Under the Medicare Shares Savings Program, Fact Sheet (April 2014). hqp:// Fee- for- Service- Payment/sharedsavingsprogram/Downloads/ ACO_Summary_Factsheet_ICN pdf Medicare Shared Savings Program Quality Measure and Performance Standards. hqp:// Fee- for- Service- Payment/sharedsavingsprogram/Quality_Measures_Standards.html State Specific Program DescripFons RFP to Provide Health Care Services to Medical Assistance and MinnesotaCare Enrollees Under Alterna2ve Payment Arrangements Through the Integrated Health Partnerships (IHP) Demonstra2on. AQachment J Sample State of Minnesota, Department of Human Services IHP Contract and Contract AQachments. Sec2on 2.2 Governance, page 53. Oregon CCO Basics Presenta2on. hqp:// Oregon Law Coordinated care organizafons rules hqp:// Source: Health Care Delivery System (HCDS) Quality Measurement Minnesota Department of Human Services. 2

3 Agenda DefiniFon: What is an ACO AlternaFve Model Comparison Other States Medicare ImplicaFons for Rhode Island RI Star2ng Point Key Considera2ons 3

4 What is an ACO? Adapted from Minnesota Part 1: Defini-on Partnerships or organizafons using accountable care delivery models that integrate medical care, mental health, substance abuse disorders, community health, public health, social services, and LTSS supported by innovafve payment and care delivery models that establish shared financial accountability across all partners, with a demonstrated commitment to con2nue to grow and develop this model of integra2on and accountability. Source: Minnesota Accountable Health Model: Con2nuum of Accountability Matrix, January 12, Minnesota Departments of Human Services (DHS) and Health (MDH) 4

5 Why are states considering/implemen2ng ACO models Goal The Triple Aim Premise We can do be3er IF we establish and support Accountable En--es THAT Part 1: Defini-on Are price and u2liza2on sensi2ve Incorporate social determinants into the defini2on of Care Have capacity for data driven decision- making Care coordina2on is provider led, with a single model Are community guided, with ac2ve community par2cipa2on in governance 5

6 Part 1: Defini-on What is an ACO? No Single dimension spectrum of ACO- like characteris2cs Spectrum of Accountable Care Beginning Level A 1. Model Spread and Payer Par2cipa2on % of lives/rev in perf/value based pmt 2. Payment Transforma2on Types of alterna-ves to FFS 3. Community Partnerships Types of provider and community partnership 4. Infrastructure/Governance to Support Shared Accountability 5. Health Informa2on Technology Adop-on and Effec-ve Use 6. Health Informa2on Exchange (HIE) Capabili-es using na-onal standards 7. Data Analy2cs Capabili2es Enable ACOs to be3er manage pa-ents and total cost of care 8. Health care delivery & community services integra2on 9. Pa2ent centeredness 10. Pa2ent/ consumer input, pa2ent engagement 11. Services included in model (delivery and payment) Advanced Level D 6 Source: Minnesota Accountable Health Model: Con2nuum of Accountability Matrix, January 12, Minnesota Departments of Human Services (DHS) and Health (MDH)

7 What is an ACO: Key Dimension Infrastructure/Governance Part 1: Defini-on Beginning ACO Governance (Level A): May only include a single organiza2on with informal partnerships with other providers and organiza2ons Advanced ACO governance (Level D): Formal, contractual or legal partnership agreement with defined community that expands the accountable en2ty. Arrangements include decision making, agreements on popula2on health goals/strategies, shared governance, data- sharing, financial arrangements Program ACO Governance Requirements IHP (MN) CCO (OR) Medicare Shared Savings Program An IHP must include an organizing en2ty and agreement of shared governance. Must have a conflict of interest policy that applies to members of the governing body IHP may be formed by the following groups of providers of services and suppliers: professionals in group prac2ce; networks of individual prac2ces; partnerships or JVs between hospitals and health care professionals; hospitals employing professionals; and other groups of providers of services and suppliers A managed care plan may par2cipate in an IHP in collabora2on with one or more of the en22es listed Contract must list governing body members, specify pa2ent reps, consumer advocates (Unclear as to requirements for makeup of body) CCOs may be a single corporate structure or a network of providers organized through contractual rela2onships Persons that share in the financial risk of the organiza2on must cons2tute a majority of the governing body Each CCO must have a governing body that includes: The major components of the health care delivery system at least two providers in ac2ve prac2ce (including a Primary care physician or nurse prac22oner and a Mental health or chemical dependency treatment provider) At least two community members At least one member of Community Advisory Council Community Advisory Council makeup: Majority of members must be consumers. Must include county gov t reps in service area. Each CCO must have a formal contractual rela2onship with any dental organiza2on that serves members of CCO in the area they reside ACO must establish governing body represen2ng ACO services providers, suppliers & Medicare beneficiaries. At least 75 percent control of the ACO's governing body must be held by ACO par2cipants. Governing body must have responsibility for oversight and strategic direc2on of the ACO Governing body members must have a fiduciary duty to the ACO ACO must provide meaningful par2cipa2on in composi2on & control of ACO governing body for ACO par2cipants/designated reps. ACO governing body must include a Medicare beneficiary representa2ve(s) served by the ACO Mul2ple Sources - See backup DRAFT FOR DISCUSSION PURPOSES ONLY DO NOT COPY OR DISTRIBUTE 7

8 Agenda DefiniFon: What is an ACO AlternaFve Model Comparison Other States Medicare ImplicaFons for Rhode Island RI Star2ng Point Key Considera2ons 8

9 Alterna2ve Model Comparison Part 2: Alterna-ve Models: Other States Many states are taking innovafve approaches to value based purchasing. State What Have they Done? Oregon: Complete, aggressive shiv to ACO model Minnesota: ACO alongside MCO contract New Jersey: ACO with gain sharing opportunity Vermont: State driven structure and single MCO Pennsylvania: ACO requirements within MCO contract Connec2cut: Moved to ASO contract for MCO services and direct to providers for care Colorado: Aggressive investment in data/analy2c infrastructure Maine: ACO with shared savings/shared risk MassachuseQs: PCCM program alongside MCO state MCO competes with other MCOs Lessons from Other States Use of a regional structure is becoming more common and valued (CO, OR, NC and others) may not apply to RI based on geographic size Specific model mawers less than the levers used in the design and execu2on of the project; Quality standards and robust data collecfon are cri2cal to assess results of standards. Quality measures must be aligned with incenfves Successful states build on what exists without adding unnecessary complexity (CO, NC, MA) Changes in payment alone is likely not sufficient to change the way in which care is delivered; efforts to support transformafon are key Source Material: Rhode Island Delivery System Op-ons and Considera-ons presenta-on by Meryl Price, President, Health Policy Ma3ers 9

10 Part 3: Alterna2ve Models Defined by Func2ons and Roles We looked at a variety of alterna-ve models: CT, MN, OR, CO, MA and NC Part 2: Alterna-ve Models: Other States MCO 1 RI Model MCO Procurement Providers State Agency MCO 2 Care delivery Set provider pmt terms Pay claims Care mgmt Compe22ve Set MCO pmt terms Pay FFS claims Care mgmt ASO En2ty ASO Model (CT) State Agency Care delivery Providers Set provider pmt terms Pay FFS claims State Agency ACO perf standards ACO/MCO contract terms Incen2ve payments? IHP/ACO (MN) ACO 1 Providers MCO 1 MCO 2 Care Mgmt Care delivery ACO 2 Providers MCO 3 Care Mgmt Compe22ve Set provider payment terms? CCO (OR) ACO/RCCO Model (CO) epccm Model (MA) CCO 1 Providers Care Mgmt Care delivery Geographic CCO 2 State Agency Providers CCO contract terms Pay full risk capita2on RCCO Support providers (analy2cs, training, repor2ng) Geographic Providers State Agency Care mgmt Care delivery SDAC Real 2me data Set provider pmt terms Pay FFS claims Network mgmt Care mgmt Care delivery VO/ PCCM State Agency Key Model Considera-ons: Who performs care management provider based en2ty or separate contracted en2ty (MCO, ASO, etc) Who sets provider payment terms - - Direct or indirect state/provider rela2onship. Is it Risk based or FFS payment? Regional vs. compe22ve model Providers Mul2ple Sources - See backup 10

11 Alterna2ve MCO Model Comparison Part 2: Alterna-ve Models: Other States Three different strategies to create value and accelerate delivery system change that change the tradi2onal role of Medicaid MCOs. Oregon replaced MCOs with CCOs No longer contracts directly with MCOs for the popula2ons included in CCO ini2a2ve However, many MCOs now contract with CCOs to provide services (e.g., claims processing, provider contracts). Some CCOs are directly owned by former Medicaid MCOs Minnesota more incremental, ACOs exist alongside MCOs Exis2ng MCO contracts in place alongside the ACP/IHP contracts MCO enrollees included in ACO pa2ent aqribu2on and cost calcula2ons MCOs required to par2cipate in the shared savings components of the IHP model Pennsylvania tradi-onal MCO with P4P Con2nues to use a tradi2onal MCO model But using MCO contracts to more directly incen2vize quality improvement at the provider level Uses P4P incen2ves at both the MCO and the provider levels Provider incen2ves incorporated into the state s contracts with MCOs, which in turn pass the incen2ves through to individual providers 11

12 Alterna2ve Models Deep Dive Oregon Part 2: Alterna-ve Models: Other States RI Model MCO Procurement Providers Care delivery Oregon CCO Structure CCO 1 CCO 2 Providers Providers Care Mgmt Care delivery Geographically dis2nct MCO 1 MCO 2 Provider pmt terms Pay claims Care mgmt Compe22ve State Agency CCO contract terms Pay full risk capita2on State Agency Set MCO pmt terms ImplementaFon Timeline Amended 1115 waiver in Mar 12, by November there were 15 CCOs in opera2on, 90% of members were enrolled StarFng Point 80% of Medicaid popula2on served by MCOs for Physical Health only. 14 fully capitated health plans CMS Commitments OR Commitments - - cost reduc2ons of 1 PP in Yr2, and 2 PPs thereaver. Commitment to integrated PH and BH. CMS Commitments - - matching flexible services payments, system transforma2on funds, HC transforma2on Center Structure they established RFP for CCOs fully capitated full risk en22es, growth consistent with waiver commitments. Integrated PH and BH. Bonus payments for quality levels, improvement. CCOs have flexibility on provider payment methods Leverage MMCO Infrastructure Ownership structure varies but all leverage infrastructure of former MMCOs for claims processing, provider contracts, back office func2ons 12

13 Alterna2ve Models: Deep Dive Oregon, Minnesota, PA Part 2: Alterna-ve Models: Other States Three different strategies to create value and accelerate delivery system change State Source of Authority Structure for Financial Alignment of IncenFves Measurement Oregon replace MCOs with CCOs Amended exis2ng 1115 waiver in March 2012 Nov 2012: 15 CCOs, 90% of members enrolled CMS approved 2011 baseline trend of 5.4%, commitment to cost reduc2ons of 1 PP in Yr2, and 2 PP thereaver; integrated BH. In return got: Match flexible services payments for things that improve health (ACs for CHF pa2ent) Approval for other expenses to support system transforma2on - - $1.9 b in 5 yrs in Transforma2on center innovator Agents (CCO support) embedded in communi2es RFP for CCOs fully capitated full risk en22es, integrated PH and BH State nego2ated baseline costs, aggregate cost growth limited to waiver specified levels Bonus for quality level,, improvement. CCOs have flexibility on payment methods CCO ownership structure varies but all leverage former MCO infrastructure for claims processing, provider contracts, back office 17 metrics in 7 core areas State publishes quarterly reports of each CCO performance against targets 2013 quality pool was $47 million (2% of CCO total paid amount) Quality pool divided amongst all CCOs, based on size (# members) and performance on incen2ve metrics Metrics selected based on transforma2ve poten2al, consumer engagement, aqainability, accuracy, feasibility, accountability, etc. MN ACOs exist alongsi de MCOs In 2010 state legislature mandated DHS to establish ACO demonstra2on, with specific structural req ts. Challenged exis2ng MCOs and FFS delivery systems to deliver more cost effec2ve care Operates alongside the MCO structure Accelerated transi2on to risk based contracts btwn Medicaid MCOs and providers Star2ng point several mature, ver2cally integrated provider groups, already par2cipa2ng in Medicare Pioneer ACO model state aligned with that Spring 2011 state did RFI, several stakeholder sessions to get input informed RFP in late 2011 Public design process providers ac2vely engaged on issues such as risk adjustment, aqribu2on DHS contracts with 6 HCDS providers - for direct care, care coordina2on services Par2cipate in shared savings/risk for TCOC, other quality metrics. Virtual or integrated. Virtual upside risk only. Integrated upside/downside DHS con2nues to contract with MCOs hold financial reserves, take on financial risk Shared risk program incorporates all MCO, FFS membership MCOs must par2cipate. Pa2ents assigned via aqribu2on formula ~60% are assigned TCOC incl. ~55-65% of claims exc. dental, supplies, transport, LTSS, res MHSA Quality measures part of exis2ng statewide quality repor2ng & measurement ini2a2ve Administered by MN DOH no new repor2ng burden for providers Providers get monthly pa2ent level data on ED admissions, hospital admissions, readmissions, other care mgmt flags quarterly reports on TCOC not real 2me, but data was a big reason why some provider groups chose to par2cipate PA Trad- i-onal MCO with P4P Small dollars but structure is interes2ng Funded equivalent of $1.00 pmpm by the state All MCOs must par2cipate, paid as pass thru from state thru MCOs to providers Con2nues to use a tradi2onal MCO model Using MCO contracts to more directly incen2vize quality at the provider level P4P incen2ves at both MCO & provider levels Provider incen2ves incorporated into the state s contracts with MCOs, which in turn pass incen2ves through to individual providers Metrics not innova2ve HEDIS 12 MCO quality measures, 11 are HEDIS Providers measured on same HEDIS measures state dictates set, carriers can add to them Lack of good data has limited program effec2veness 13

14 Medicare ACOs Part 2: Alterna-ve Models: Medicare Medicare Shared Savings Program Eligible providers, hospitals, and suppliers must create an Accountable Care Organiza2on (ACO) to par2cipate Shared Savings: ACOs that meet quality performance standards receive a share of the savings if assigned beneficiary expenditures are below its own specific updated expenditure benchmark Shared Losses: ACOs are also held accountable for sharing losses and may be required to repay Medicare for a por2on of losses (expenditures above its updated benchmark) ACOs choose one of two program tracks: Track 1: shared savings only arrangement. Track 2: share in savings and losses, in return for a higher share of any savings it generates. Pioneer ACO Program Ini2a2ve launched by CMS Innova2on Center for organiza2ons with experience operafng as ACOs. Years 1-2: shared savings payment arrangement with higher levels of savings/risk than Shared Savings Program Year 3: eligible organizafons can transifon away from fee- for- service payment to per- beneficiary per month payment amount and full risk arrangements (op2onal to con2nue through years 4-5) Mul2payer: requires par2cipa2ng ACOs to engage in similar arrangements with commercial/other payers by end of Year 2. Pioneer ACOs must generally be responsible for the care of at least 15,000 aligned beneficiaries (5,000 for rural ACOs) Next GeneraFon ACO Program Offers financial arrangements with higher levels of risk and reward than MSPP/Pioneer. Offers a selec2on of payment mechanisms to enable a gradua2on from FFS reimbursements to capita2on. Uses refined benchmarking methods that rewards improvement in cost containment and ul2mately transi2ons away from comparisons to historical expenditures. Includes several benefit enhancement tools to improve engagement with beneficiaries Source: CMS website, Program Fact Sheets 14

15 Lessons from Other States Part 2: Alterna-ve Models Use of a regional structure is becoming more common and valued (CO, OR, NC and others) may not apply to RI based on geographic size Specific model mawers less than the levers used in the design and execu2on of the project; Quality standards and robust data collecfon are cri2cal to assess results of standards. Quality measures must be aligned with incenfves Successful states build on what exists without adding unnecessary complexity (CO, NC, MA). Changes in payment alone is likely not sufficient to change the way in which care is delivered; efforts to support transformafon are key Source Material: Rhode Island Delivery System Op-ons and Considera-ons presenta-on by Meryl Price, President, Health Policy Ma3ers 15

16 Agenda DefiniFon: What is an ACO AlternaFve Model Comparison Other States Medicare ImplicaFons for Rhode Island RI Star2ng Point Key Considera2ons 16

17 RI Star2ng Point The Triple Aim RI StarFng Point Established MCO infrastructure With some cri2cal strengths (network/access, member service, rate adequacy) and opportuni2es for improvement (data/analy2cs/metrics, risk arrangements) Limited and overlapping provider risk bearing capacity We do not have geographically dis2nct en22es Mixed Provider Readiness Some Interested par2es - - sophis2cated medical homes looking for alterna2ve payment arrangement that pushes integra2on with specialty care and hospitals Will be an investment/infrastructure build only certain en22es can support this Rhode Island State AdministraFve Capacity State staff, infrastructure in managed care. Would need to develop new capabili2es Unique Hospital infrastructure Successful ACOs generally have hospitals involved how to do that here? Part 3: Implica-ons for RI RI Specific ACO Opportunity 1. An intermediate structure for financial alignment of incenfves across providers All par2es must benefit when total cost of care is reduced. Provider payments must incen2vize coordina2on of total cost of care 2. A way to address social determinants Need a way to iden2fy, pay for & provide services that address social determinants (e.g., housing, food) in a way that is acceptable to CMS 3. Maintain Current Program Strengths Broad Networks, strong access; Robust Member services and supports, Rate adequacy 17

18 Some Key ACO Model Decisions Part 3: Implica-ons for RI WHY: Program ObjecFves Triple Aim Specific program goals, principles, premise for reform WHAT: DefiniFonal Governance, Standards WHAT: Structural Inside vs. alongside MCOs Popula2ons served Services provided Regional vs compe22ve HOW: Provider Capacity: New Provider Infrastructure Needed Data/analy2c capacity: Metrics, Risk adjustment, AQribu2on Approvals: CMS, Waiver impact Implementa2on plan and 2meline WHO: Member Impact Member Protec2on Choice AQribu2on and networks 18

19 Backup 19 19

20 Spectrum of Accountable Care Dimensions Beginning (Level A) Advanced (Level D) 1. Model Spread and Payer ParFcipaFon % of lives/rev in perf/ value based pmt 2. Payment TransformaFon Types of alterna-ves to FFS 3. Community Partnerships Types of provider and community partnership 4. Infrastructure/ Governance to Support Shared Accountability 5. Health InformaFon Technology Adop2on and Effec2ve Use 6. Health InformaFon Exchange (HIE) Capabili-es using na-onal standards Care coordina2on fees received by en2ty Performance/value based fees or incen2ve payments by most payers (or significant %) < 5% of revenue from perf/value based payments Health care home or similar care coordina2on fees, quality improvement/incen2ve payment Informal rela2onships between health care providers and community providers or organiza2ons through basic referrals May include only a single organiza2on with informal partnerships with other providers and organiza2ons Alterna2ve types of payment arrangements for majority of payers/ consumers OR More than 30% of total revenue from performance based or value based payment Most arrangements include some level of risk payment at or moving toward prospec2ve or global payment; quality component of payment includes popula2on health measures/ accountability; community partners are sharing in accountability for cost, quality and popula2on health and included in the financial model in some form Wide range of formal partnerships between community providers/ organiza2ons and health care delivery providers working collabora2vely within defined community to transform popula2on health incl: coordina2on of care collabora2on on clinical and popula2on health improvement ac2vi2es, etc leading to sustained improvement in broad popula2on health metrics Formal, contractual or legal partnership agreement with defined community that expands the accountable en2ty. These arrangements include decision making, agreements on popula2on health goals/strategies, shared governance, data- sharing, and some financial arrangements EHR in place or organiza2on plans to implement Widespread adop2on of EHR and other HIT that can provide accountable an EHR by specified date care- related processes and func2ons, across all organiza2ons and se}ngs EHRs should either be cer2fied by the Office of within partnership, including par2cipa2ng community partners. the Na2onal Coordinator (ONC) pursuant to the EHRs are used to provide addi2onal comprehensive func2ons such as: Federal Health Informa2on Technology for o care coordina2on, cohort management, Economic and Clinical Health (HITECH) Act or a o consumer and caregiver rela2onship management, qualified EHR as defined in State statutes o clinician engagement o Financial management, repor2ng o Knowledge management, Con2nuous quality improvement Push capabilifes Pull/query capabilifes (the ability to send or receive direct secure (the ability to securely query for consumer informa-on from mul-ple messages are established with at least one loca-ons) are established with mul2ple unaffiliated partners for mul2ple use unaffiliated partner) cases, including with community partners 20 DRAFT FOR DISCUSSION PURPOSES ONLY DO NOT COPY OR DISTRIBUTE Source: Minnesota Accountable Health Model: Con2nuum of Accountability Matrix, January 12, Minnesota Departments of Human Services (DHS) and Health (MDH)

21 Spectrum of Accountable Care (page 2 of 2) Dimensions Beginning (Level A) Advanced (Level D) 7. Data AnalyFcs CapabiliFes Enable ACOs to be3er manage pa-ents and total cost of care 8. Health care delivery and community services integrafon and coordinafon 9. PaFent centeredness 10. PaFent/ consumer input, pafent engagement 11. Services included in model (delivery and payment) Use of consumer registry or other data warehousing to iden2fy and/or stra2fy popula2ons (i.e. popula2ons with certain risk factors), performance repor2ng for some QI ac2vity within a single organiza2on Coordina2on and integra2on of health related ac2vi2es within a single organiza2on (e.g. care coordinator sits within clinics or is co- located) May include some co- loca2on or consulta2on with other providers or organiza2ons Principles of pa2ent centered care that include family and cultural values and preferences are included in the organiza2on s vision & mission statements Pa2ent/consumer input is accomplished using a pa2ent sa2sfac2on survey administered sporadically at the organiza2on or enterprise level. Services directly provided or immediately impacted by one organiza2on/sector (e.g. just medical or LTSS) Part 4: Where do we go from here Expanded level of data repor2ng including integra2on and analy2cs with mul2ple community partners, or inclusion of consumer and popula2on data from community partners in registries/ databases for QI, care coordina2on, and popula2on health Care coordina2on and health improvement ac2vi2es includes broad range of services and popula2ons (including post- acute care, social services, and behavioral health), and, includes formal rela2onships between providers and mul2ple community organiza2ons to iden2fy coordina2on and health improvement barriers and strategies, develop popula2on health improvement goals and metrics. Integra2on includes: o Medical/primary care/specialty care, sub- acute o Behavioral health o LTSS/post- acute o Social services o Public health/ preven2on o Other public/ private or community svcs Principles of pa2ent- centered care that include family and cultural values and preferences are systema2cally and consistently used to guide organiza2onal changes, plan care delivery and measure system performance as well as care interac2ons at the prac2ce level Pa2ent/consumer engagement is accomplished by ge}ng frequent and ac2onable input from pa2ents and families who ac2vely par2cipate on interdisciplinary quality improvement/other advisory teams that provide meaningful opportuni2es for input into quality improvement. Pa2ent/consumer input tools are available in mul2ple languages to reflect popula2ons served. Accountability at some level of popula2on health including all health care, behavioral health and LTSS within a defined community; Accountability may be shared to varying degrees for popula2on health including metrics and cost. Iden2fied community services included as part of a model that leads to health improvement for iden2fied broad metrics. Source: Minnesota Accountable Health Model: Con2nuum of Accountability Matrix, January 12, Minnesota Departments of Human Services (DHS) and Health (MDH) DRAFT FOR DISCUSSION PURPOSES ONLY DO NOT COPY OR DISTRIBUTE 21

22 Medicare ACOs: Shared Savings, Pioneer Part 2: Alterna-ve Models: Medicare Medicare Shared Savings Program Eligible providers, hospitals, and suppliers must create an Accountable Care Organiza2on (ACO) to par2cipate 338 Medicare Shared Savings Program par2cipa2ng ACOs as of May 2014 Shared Savings Program Structure o Overview: rewards ACOs that lower growth in health care costs while mee2ng quality standards, pu}ng pa2ents first o Shared Savings: ACOs that meet quality performance standards receive a share of the savings if assigned beneficiary expenditures are below its own specific updated expenditure benchmark o Shared Losses: ACOs are also held accountable for sharing losses and may be required to repay Medicare for a por2on of losses (expenditures above its updated benchmark) ACOs choose one of two program tracks. o Track 1: shared savings only arrangement o Track 2: share in savings and losses, in return for a higher share of any savings it generates. Pioneer ACO Program Ini2a2ve launched by CMS Innova2on Center for organiza2ons with experience operafng as ACOs. 23 Pioneer ACOs par2cipa2ng as of May 2014 Purpose of Pioneer ACO program is to: o Show how par2cular ACO payment arrangements can best improve care and generate savings for Medicare o Test alterna2ve program designs to inform future rulemaking for the Medicare Shared Savings Program Structure: o Years 1-2: shared savings payment arrangement with higher levels of savings/risk than Shared Savings Program o Year 3: eligible organizafons can transifon away from fee- for- service payment to per- beneficiary per month payment amount and full risk arrangements (op2onal to con2nue through years 4-5) Addi2onal Requirements: Mul2payer: requires par2cipa2ng ACOs to engage in similar arrangements with commercial/other payers by end of Year 2. Pioneer ACOs must generally be responsible for the care of at least 15,000 aligned beneficiaries (5,000 for rural ACOs) 22

23 Alterna2ve MCO Model Assessment: Medicare Shared Savings Program Metrics Medicare Shared Savings Program Quality Measures Table: 33 ACO Quality Measures Domain Measure Description Pay-for-Performance Phase In R= Reporting P= Performance PY1 PY2 PY3 Patient/Caregiver Experience ACO #1 Getting Timely Care, Appointments, and Information R P P Patient/Caregiver Experience ACO #2 How Well Your Doctors Communicate R P P Patient/Caregiver Experience ACO #3 Patients Rating of Doctor R P P Patient/Caregiver Experience ACO #4 Access to Specialists R P P Patient/Caregiver Experience ACO #5 Health Promotion and Education R P P Patient/Caregiver Experience ACO #6 Shared Decision Making R P P Patient/Caregiver Experience ACO #7 Health Status/Functional Status R R R Care Coordination/Patient Safety ACO #8 Risk Standardized, All Condition Readmissions R R P Care Coordination/Patient Safety ACO #9 ASC Admissions: COPD or Asthma in Older Adults R P P Care Coordination/Patient Safety ACO #10 ASC Admission: Heart Failure R P P Care Coordination/Patient Safety ACO #11 Percent of PCPs who Qualified for EHR Incentive Payment R P P Care Coordination/Patient Safety ACO #12 Medication Reconciliation R P P Care Coordination/Patient Safety ACO #13 Falls: Screening for Fall Risk R P P Preventive Health ACO #14 Influenza Immunization R P P Preventive Health ACO #15 Pneumococcal Vaccination R P P Preventive Health ACO #16 Adult Weight Screening and Follow-up R P P Preventive Health ACO #17 Tobacco Use Assessment and Cessation Intervention R P P Preventive Health ACO #18 Depression Screening R P P Preventive Health ACO #19 Colorectal Cancer Screening R R P Preventive Health ACO #20 Mammography Screening R R P Preventive Health ACO #21 Proportion of Adults who had blood pressure screened in past 2 years R R P At-Risk Population Diabetes Diabetes Composite ACO #22 26 At-Risk Population Diabetes ACO #27 ACO #22. Hemoglobin A1c Control (HbA1c) (<8 percent) ACO #23. Low Density Lipoprotein (LDL) (<100 mg/dl) ACO #24. Blood Pressure (BP) < 140/90 ACO #25. Tobacco Non Use ACO #26. Aspirin Use Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) R P P R P P At-Risk Population Hypertension ACO #28 Percent of beneficiaries with hypertension whose BP < 140/90 R P P At-Risk Population IVD ACO #29 At-Risk Population IVD ACO #30 Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl Percent of beneficiaries with IVD who use Aspirin or other antithrombotic R P P R P P At-Risk Population HF ACO #31 Beta-Blocker Therapy for LVSD R R P At-Risk Population CAD Notes: PY = Performance Year CAD Composite ACO #32 33 ACO #32. Drug Therapy for Lowering LDL Cholesterol ACO #33. ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD R R P Medicare Shared Savings Program Quality Measure and Performance Standards. hqp:// Fee- for- Service- Payment/ sharedsavingsprogram/quality_measures_standards.html Page 1 of 1 23