Payor Perspectives on Provider Realignment and ACOs Joel L. Michaels March 15, 2011
Overview Issues to be addressed Medicare Shared Savings Program overview ACO organization options Health care reform insurance market reforms Critical issues when partnering with commercial payors Capital infusion Exclusivity Member attribution Benefit design Payment arrangements Retained vs. delegated services Focus on ACO development from the payor perspective 2
Medicare Shared Savings Program Health care reform directs HHS to create structure for Medicare to compensate ACOs on quality and costsavings (PPACA Section 3022) Must be established by January 1, 2012 Regulation expected in next two weeks Characteristics Various provider types and legal structures/no need for an insured vehicle 5,000 beneficiaries Three year agreements CMS statements suggest there will be no downside provider risk (MedPAC has argued for downside risk) Beneficiary can choose providers inside or outside ACO 3
Medicare Shared Savings Program (cont.) Format of Medicare Shared Savings Program may impact commercial payors Commercial payors may want to create similar incentives to maximize impact on provider behavior Replicating quality metrics used by CMS may also create efficiencies But commercial payors may need to go beyond the terms of the Medicare Shared Savings Program Upside potential only may be acceptable at first, but many payors will want downside risk as well May need stronger conditions on patient attribution and use of non- ACO providers Issue of reconciling contract terms with payor and CMS requirements for ACOs under Medicare Share Savings Program 4
Medicare Advantage as a Preferred Approach Medicare Advantage ( MA ) could be a vehicle for payment and delivery reforms May allow providers and payors more flexibility Payors could go beyond Shared Savings Program for their MA populations with risk sharing and benefit limitations that will help influence consumer conduct Example: Aetna has been using the accountable care model since 2007 for 20,000 MA members 5
ACO Organizational Sponsor Types Hospital/Affiliated IPA/Medical Group/Medical Foundation working off of the clinical structure of the existing delivery system with a focus on both outpatient and inpatient service capabilities Medical Group/IPA including multispecialty physician groups that may have experience with capitation and risk assumption models Provider delivery systems that also have an insurance vehicle capacity (such as Geisinger and Intermountain) 6
ACO by Contract vs. Legal Entity Payor s use of contractual arrangements with existing physician groups, IPAs, Medical Foundations and PHOs Formation of a new legal entity by the provider delivery system to serve as the ACO Medicare Shared Savings Program: Establish a formal legal structure having shared governance that allows the ACO to distribute shared savings payments to participating providers and suppliers. Will the pending CMS regulations clarify that contract affiliations constitute an adequate legal structure for ACO qualifying purposes? 7
ACO Collaborative Models: the Contract Option BCBSMA: Alternative Quality Contract BCBSMA offered provider groups the option to contract based on global payment as opposed to FFS 5 year contract term as opposed to terms of 1-3 years Payment: Negotiated annual budget with incentives for meeting quality targets Annual budget increases are 50% of projected increase for HMO network Budget is risk-adjusted on an annual basis Physicians share upside and downside risk Quality incentives based on absolute and not relative performance Providers paid on FFS basis for services to members during contract year and then payments are reconciled against the predetermined budget at end of contract year Eligibility: Provider group must care for at least 5,000 members in BCBSMA HMO or POS plans Participation: Twelve provider groups currently participating ranging from 72 physicians to over 1,300 physicians 8
Insurance Market Reforms Health care reform significantly impacts payors* Medical loss ratio ( MLR ) requirements Premium rate increase review Expansion of coverage Prohibition on preexisting condition exclusions These changes mean payors are under enormous cost pressures now Providers need to understand these market changes, which are taking place right now * Payor as used herein may only refer to health insurance issuers in connection with MLR requirements, premium rate review, the insurance exchanges and certain other health reform requirements. 9
Medical Loss Ratio Medical Loss Ratio Requirements Requires payors to spend 80% (individual and small group market) or 85% (large group market) of premium revenue on medical expenses and quality improvement expenses Effective for the 2011 calendar year Only applies to health insurance coverage and does not include governmentfunded coverage (Medicare Advantage or Medicaid Managed Care) or selffunded employer coverage Payors must provide premium rebates to enrollees if MLRs do not meet the required thresholds MLRs are calculated separately for the individual, small group, and large group markets in each State Some states are obtaining waivers of the 80% standard for their individual markets Interim final rule released Dec. 1, 2010 describing how payors are to classify expenses 10
Medical Loss Ratio (cont.) Payors have an incentive to maximize their quality improvement activity expenses Quality improvement activities are those that: Improve health outcomes; Prevent hospital readmissions through a comprehensive program for hospital discharge; Improve patient safety, reduce medical errors, and lower infection and mortality rates; Implement, promote, and increase wellness and health activities; and Enhance the use of health care data to improve quality, transparency, and outcomes and support the meaningful use of health information technology. 11
Medical Loss Ratio (cont.) Quality improvements are integral to the ACO model Investments by payor to help the ACO achieve quality improvement standards will have a positive MLR impact Payments to the ACO for quality improvement activities will have a positive MLR impact Alternative payment models associated with ACOs could positively impact a payor s MLR Provider incentive and bonus payments are included in medical costs Capitation payments to physicians will be included in medical costs 12
Premium Rate Increase Review Payors face pressure to limit premium increases Health care reform requires HHS and States to establish a process for reviewing unreasonable increases in premiums for health insurance coverage Proposed rule released Dec. 23, 2010 2011: Proposed rate increases over 10% in the small group and individual market would be subject to review After 2011: State-specific thresholds will be set Payors would have to justify the proposed increase and disclose the justification and increase publicly ACO arrangements that reverse curved inflationary trends will be a priority for payor 13
2014: Important Year for Payors Insurance Exchanges Individual and small group coverage will be offered through state insurance exchanges Allows consumers to compare price and benefits Payors must offer the essential health benefits, which includes a broad range of medical services Will influence payors to find ways to provide a broad range of benefits at a competitive price the ACO delivery system reforms could be a key component Payors must begin developing these arrangements now so that they are effective and can be broadly implemented in 2014 14
2014: Important Year for Payors (cont.) Expansion of insurance coverage Guaranteed issue requirement Prohibition on preexisting condition exclusions extended to all individuals Payors will not be able to avoid high-risk individuals once individual purchase mandates are in place Payors are prohibited from increasing rates based on health status Lowering costs for enrollees with chronic conditions will be critical to offering competitive premiums Need to start implementing delivery system and payment reforms now to be ready for 2014 15
ACO Collaborative Models BlueCross and BlueShield of Illinois and Advocate BCBSIL: Largest payor in Illinois Advocate: Owns ten hospitals in Illinois Three-year agreement Payment Rate increases are limited over three-year period and Advocate must meet specified performance targets Advocate retains a share of cost-savings over the course of the agreement BCBSIL pointed to health care reform as driving these arrangements Insurance exchanges in 2014 and the need to offer affordable benefit packages MLR requirements also cited as reason to control costs and invest in quality improvement 16
Collaboration with Payors Essential to the penetration of the commercial insurance as well as Medicare Advantage markets Will be important in the expansion of the Medicaid market in 2014 as a result of health care reform Advantages to providers will be to leverage off of the capabilities of the payor: Capital Health information data Claims administration Actuarial skills Provider payment Network administration Medical management capabilities Capital infusion by the payor into the ACO delivery system itself will raise additional questions as to the scope and nature of the collaboration 17
Payor Collaboration Issues: Capital Infusion Improvement of integration of the clinical delivery system, which is unique to the particular ACO Expansion of electronic health records utilization by ACO providers Expanding disease management programs to assist the ACO in managing health care costs Creation of a patient-centered medical home as a critical entry point to the ACO delivery system 18
Payor Collaboration Issues: Exclusivity To the extent that payor capital investment is involved that is unique to the ACO delivery system, will the issue of exclusivity need to be addressed? Exclusivity at the payor/aco level as opposed to the independent practitioner level Potential antitrust considerations in evaluating geographic and product markets and the relative positions of each party Primary care physician exclusivity issues in connection with the ACO attribution model 19
Payor Collaboration Issues: The Challenges of Attribution Prospective vs. retrospective assignment Dartmouth model where patients are empirically assigned to a provider based on the patient s historical care patterns (using two years of claims data) How are referrals and the control over referrals managed both within the ACO and outside of it? What is the consumer s understanding as to the issue of provider choice in the ACO environment? 20
Payor Collaboration Issues: Attribution (cont.) Significance of primary care physician s role as an entry point to the ACO delivery system HMO primary care gatekeeper models Attribution vs. assignment and the politics of choice Importance of attribution to the critical mass of insureds necessary to make the model work effectively 21
Payor Collaboration Issues: Benefit Design HMO model HMO delivery system product with coverage limited to contracted provider network Does the HMO product have sufficient market penetration to meet the critical mass requirements of the ACO model? PPO model Use of PPO product design with reduced copayments or coinsurance for the use of ACO network providers Is a preferred tier of providers within an existing preferred network permitted under state insurance law? Medicare Advantage benefit designs and the ability to manage health care services 22
ACO Collaborative Models Blue Shield of California, Catholic Healthcare West, Hill Physicians Created ACO to manage the care of 40,000 CALPERS members Goal: Keep healthcare costs flat in 2010 Utilized existing benefit product Blue Shield HMO benefit product Members were chosen that had a primary care physician affiliated with Hill Physicians Challenge: Parties said biggest challenge centered around data creation, sharing, and access Results: First year resulted in better care and millions of dollars in savings Zero percent premium increase for 2011 23
Payor Collaboration Issues: Payment Arrangements Various options to consider Shared Savings Bundled Payments Full or partial capitation Relevant government program demonstrations Many variations are possible in each broad category Each type of payment arrangement will create unique legal issues and contracting concerns Quality performance measures as a central element to each payment approach 24
Payor Collaboration Issues: Payment Arrangements (cont.) Shared Savings Model Many different configurations FFS with bonus for meeting quality target FFS with bonus for cost-savings against a medical services budget and quality bonus FFS with eligibility for bonus for cost-savings based on meeting threshold quality metrics FFS with potential bonus or penalty for performance against a medical services budget Choice of quality measures important and will require payor to develop systems to monitor provider performance Payor will want to confirm the shared savings are being appropriately distributed if the ACO assumes this responsibility Consider downside provider payment risk and clinical integration questions to address potential antitrust concerns 25
Payor Collaboration Issues: Payment Arrangements (cont.) Bundled payments Key issues May be difficult to utilize on a wide scale immediately Likely will be paired with a FFS or shared savings model Focus on certain conditions where bundled payments are appropriate because of a predictable care cycle Provider must be willing to accept upside and downside risk Payor perspective Like FFS which is volume-based, could create an incentive to generate more episodes of care Must ensure that it does not discourage the provision of medically necessary services 26
Payor Collaboration Issues: Payment Arrangements (cont.) Full or Partial Capitation Key issues May raise state licensing and solvency requirements for the ACO Many providers are unwilling or unprepared to accept this level of risk for patient services (except providers who have had significant experience managing capitation risk successfully) Partial capitation involving a defined subset of services may be more realistic at outset Payor perspective Eliminates FFS incentive for volume over quality Need to ensure all medically necessary services are provided HMO product design may be a limitation 27
Payor Collaboration Issues: Payment Arrangements (cont.) Relevant Demonstration Projects Health care reform requires CMS to create a national pilot on payment bundling for Medicare by Jan. 1, 2013 Health care reform establishes various Medicaid demonstration projects related to ACO development Bundled payment demonstration in up to 8 states Global capitated payment structure for safety-net hospitals in 5 states Pediatric ACO demonstration project with shared savings payments Emergency psychiatric services demonstration project in up to 8 states Payors may need to implement ACO payment reforms sooner and on a larger scale 28
Payor Collaboration Issues: Administrative Services ACO and payor must determine who is responsible for various services: Payor may have unique experience and expertise in certain functions: Claims adjudication Data analysis Utilization management services Calculation of ACO/physician bonus amounts Network contracting Marketing ACO may want responsibility for functions that also impact utilization: Care management Quality management Chronic disease management 29 29
Payor Collaboration Issues: Administrative Services (cont.) ACO provider payments and distributions If payor handles provider payments, other potential legal issues, such as anti-kickback and Stark concerns, may be diminished Regardless of which services are delegated, payor will need to exercise oversight Examples may include utilization management and other functions that impact care provided to members Payor will likely require contract to allow for revocation of delegated services Medicare Advantage delegation and oversight requirements will also need to be considered 30
Payor Collaboration Issues: Term and Termination of the ACO Agreement Longer term contracts will be required given the nature of the change in financial incentives Three to five years may be more standard What are the provisions for accountability during the transition and how may the agreement be terminated before its scheduled termination? Termination implications are potentially greater for both the payor and the delivery system, particularly in models that are highly collaborative in nature 31
Unique Challenges in the Self-Funded Market Issue of risk transference from payor to provider could raise potential regulatory issues for the provider entity assuming the risk How does the self-funded employer pay for administration that now involves quality management as well as claims processing? How are provider incentive payments and shared savings distributions calculated and allocated to each self-funded employer group? Unique legal issues may exist when employer sponsor is also the health system Potential ERISA fee disclosure issues 32
Contact Information Joel L. Michaels 202.756.8375 jmichaels@mwe.com 33