Applying for MSSP: Why it s worth it and lessons learned to get it done

Applying for MSSP: Why it s worth it and lessons learned to get it done April 25, 2012 Note: This presentation is posted at www.premierinc.com/advisorlive Copyright 2012 Premier, Inc. All rights reserved.

Speakers Jacqueline Gisch, RN, MSN, Vice President, Quality, Aurora Health Care Joe Damore, FACHE, Vice President of Engagement and Delivery, Premier healthcare alliance 1

Insert polling question Are you considering applying for the Medicare Shared Savings Program? 3

INDUSTRY UPDATE 4

Healthcare environment update 5

What does failure of the Super Committee mean? The failure of the Joint Select Committee ( Super Committee ) to reach a deal by November 23, 2011 triggers across the board cuts totaling $1.2 trillion from FY 2012-2021 that will take effect starting January 2013 Projected Savings from Sequestration (in Billions) from CBO, FY 2013-2021 1 100% 80% 60% 40% $47 $123 $169 $294 Other2 Medicare Reduced Debt Service Costs Nondefense Discretionary 20% 0% $454 Defense 6

$123B Medicare Sequestration hits providers most Healthcare Cuts Medicare cuts are limited to 2% for all non-exempt Medicare programs and activities Concentrated largely on providers and plan payments Programs exempt from cuts: Medicaid, CHIP, Part D, Catastrophic Coverage policies, and ACA exchange premium subsidies. 15% cut in exchange costsharing and related subsidies in addition to Medicare spending 8% 4% 15% Share of Total FY13-FY21 Cuts, by Medicare Service Type 1 14% 8% 12% 32% 7% Hospital Inpatient Care Skilled Nursing Facilities Physician Fee Schedule Hospital Outpatient Services Group Plans (includes MA) 7

Change is happening now The push/pull to accountable care Track 1 Track 2 Cuts to Medicare FFS System Readmissions penalty Penalty = 5x readmissions payment HACs penalty Partnership for Patients Will set a higher bar Value based purchasing Efficiency measure: total spending 3 days prior/30 days post Outcomes including mortality Meaningful use penalties Private Payors and Medicaid Bundled payment: 2016? Disrupt Existing System MSSP Pioneer Flexible design; retro and prospective attribution State/Federal duals demo State partnership; eased enrolling Medical home demo; new CMMI Primary Care Initiative Reducing readmissions from nursing homes demo Bundled payment demos 8

Movement to integrated care, new payment models and risk Value Based Purchasing: HACs, quality, efficiency, cuts Bundled Payment Shared Savings Capitation + + PfP High Performing Hospitals Most efficient supply chain Best outcomes in quality, safety Waste elimination Satisfied patients High Value Episodes DRG and episode targeting Care models and gainsharing Data analytics Cost management Population Management Population analytics Care management Financial modeling and management Legal Physician integration

Leading healthcare providers are going full steam ahead Currently over 164 ACOs in 41 states* First ACOs part of the PGP Demonstration project beginning in 2006 99 of these ACOs sponsored by hospital systems 38 of these ACOs sponsored by physician groups 27 of these ACOs sponsored by insurers 32 CMMI Pioneer participants, program began Jan 2012 Roughly 30% physician organization led Includes JSA Medical Group (Orlando, Tampa Bay, surrounding So. FL) 27 organizations recently selected for the Medicare Shared Savings Program (MSSP) Program began April 2012, next cohorts July 2012 & Jan 2013 Majority of organizations physician organization led Organizations include: Accountable Care Coalition of Coastal Georgia (CHS) Ormond, FL Accountable Care Coalition of the Mississippi Gulf Coast (CHS) -- Clearwater, FL Florida Physicians Trust Winter Park, FL Primary Partners Clermont, FL West Florida ACO Trinity, FL * Source: Growth and Dispersion of Accountable Care Organizations: Leavitt Partners 2011 10

PGP demonstration sites, CMMI Pioneer participants and MSSP ACO locations As of 4/12/2012 WA CA OR NV ID AZ UT MT WY CO NM ND SD NE KS OK MN IA MO AR WI IL MI IN KY TN OH PA WV VA NC SC ME VT NH MA NY RI CT NJ DE DC MD MS AL GA GA TX LA FL Medicare Shared Savings Program ACO (27) Medicare Physician Group Practice Demonstration (10) CMMI Pioneer ACO (32) 11

Medicare Shared Savings Program participants Ten Organizations in the PGP Demonstration Program (2006 to present) Thirty-Two CMMI Pioneers (starting January, 2012) Twenty-Seven MSSP Participants (starting April, 2012) Over 150 Applicants to CMS (selected participants begin July 1, 2012) NOI due by June 15 and Applications due August 30 (to begin January 1, 2013) 12

MEDICARE SHARED SAVINGS PROGRAM (MSSP) 13

What is the Medicare Shared Savings Program (MSSP)? Elective program offered by CMS which permits qualified organizations to form a Medicare approved ACO and earn bonuses through shared savings Shared savings are determined by the fee for service payments (for Medicare Parts A and B) for Medicare recipients attributed to the primary care physician members in the ACO ACO can select one of two models (Track 1 or 2) and distribute savings to program participants, including independent physicians Track 1 is a model (for three years) which has only upside risk (shared savings at 50%) based upon fee for service payments vs. the targeted Medicare per capita expenditures for the enrolled Medicare population Track 2 has both upside and limited downside risk (with a 60/40% shared savings opportunity) CMS will provide each organization with 3 years of Medicare claims data for their attributed population Federal Government provides waivers/protections from Stark, Antitrust, and IRS rules 14

Medicare Shared Savings Program Questions organizations should be asking Is my hospital/system ready for this? Are my physicians aligned and ready to lead? How are capabilities assessed and measured? What infrastructure needs to be in place? What changes in care delivery need to be accounted for?? What are the potential costs/benefits to participate? What savings should I expect if I participate? How long should it take to earn those savings? How is our market being impacted? Are our competitors proceeding with MSSP or another CMMI pilot program? Are there physician groups, physician organizations or insurers in our market looking to develop an ACO? 15

2012 MSSP activity 27 ACOs will participate as of April 1 st Mostly physician groups, but 10 Hospitals included 50 applications submitted for April 1 st 2012 start date Rough geographic breakdown: 30% Northeast 30% Southeast 20% Western 8% Midwest 8% South July 1 st 2012 is the next start date for MSSP Applications were due by organizations on March 30 th 2012 For anyone who doubted, today s numbers should give us tremendous confidence Acting Deputy Administrator Jonathan Blum 16

Timeline for January 1, 2013 participation For those who have not already applied, the next available MSSP start date is January 1 st 2013 Notice of Intent (NOI) must be submitted by June 15 th 2012 Submission of an NOI does not require an organization to submit an application Without submission of the NOI, an organization will not be able to submit an application MSSP application due August 30 th 2012 Premier s MSSP Application Cohort II beginning June 2012 Cohort kickoff meeting on June 5 th at Breakthroughs MSSP educational session on June 5 th at Breakthroughs 17

Premier s MSSP Application Cohort services Cohort facilitation and support * 1. Education 9. Post Application Measurement 2. Rules / Regulation Clarification 8. Application Support Measurement Care Improve and ment Benchmarking Advocacy and Legal Support 3. NOI Support Financial and contract Modeling Claims & Other Data Analysis 7. Model Contracting Templates 6. Gainsharing Modeling 5. Data Analysis * There will be a foundational level of support offered to all members, however additional fees for some services may apply. 18

Additional Information MSSP Cohort overview webinars o May 8 th 3:30 4:30PM EST (featuring Hackensack) o May 23 rd 2:00 3:00PM EST MSSP Application Cohort II starts June 2012 o Cohort kickoff meeting on June 5 th at Breakthroughs Email Parker_Marsh@premierinc.com for further information 19

The Broader Policy context CMS orienting efforts toward Triple Aim Better Care for Individuals Better Health for Populations Lower Growth in Expenditures Source: Health Care Advisory Board interviews and analysis. 20

Insert polling question Do you represent an integrated delivery system? 21

Aurora Health Care Private, not-for-profit integrated health care provider 31 counties, 90 communities 15 hospitals 157 clinic sites 1,416 employed physicians Largest homecare organization in the state 82 retail pharmacies 30,000 caregivers 91,000 inpatient discharges 2 million hospital and outpatient visits 4 million ambulatory care visits Revenues greater than $4.0 billion 22

Why apply for the Medicare Shared Savings Program? General reasons Ability to design for, and reward for, the care clinicians truly want to provide Additional support for re-design changes Delicate balance between existing fee for service mechanisms and alternative payment mechanisms Ability to test out ideas Encourage physician engagement Additional Aurora Health Care reasons Application supported existing work Project will assist in bringing a new Medical Group on board Relationship development Organizational integration 23

Application process first steps Complete the Notice of Intent to Apply (electronically) Organization's Tax ID number Type of ACO Shared Savings Track Entity legal name Contact information Cannot apply if this is not completed Once completed, receive acknowledgement via email ACO number AXXXX Additional instructions to obtain access to submission portal Health Plan Management System (HPMS) 24

Application process how to organize work Assign a project manager Communicate to organization Key stakeholders Administrative Leadership Clinical leadership Clinical staff Recruit content writers Internal expertise Create a work plan Set expectations Set deadlines 25

Application topics Organizational Overview Legal Requirements Governance/Leadership Participation in other Shared Savings initiatives Financial Information Provider Information Data Sharing Required Clinical Processes and Patient Centeredness 26

Governance and leadership Organizational chart with committees List of committee members, including role and structure Required to use an excel template Difficult to assure all the information is included Job descriptions for senior leaders administrative and clinical Must address specific role in the ACO Must address ability to influence or direct clinical practice to improve efficiency processes and outcomes 27

Governance and leadership Lesson Learned Application written for groups of independent practitioners to come together to form an ACO As an integrated delivery system, we felt that there was not a lot of additional structure needed Redesigned based on additional request Because of Tax ID issue, the governing board was not 75% providers (according to the definition) Retooled structure to illustrate the significant level of involvement the providers would have in the detail of governance Job Descriptions Added AACO detail to existing job descriptions using template language for both role and experience 28

Financial Because we are an IDN, we chose not to distribute savings to providers but to re-invest in infrastructure Specified exactly how we planned to re-invest, including percentages to different areas Programs Staff/FTEs Beneficiary Engagement 29

Provider agreements We executed few contracts since the only members of the ACO are already part of Aurora Provided the draft agreement Templates are available 30

Data sharing We stated that we will be requesting data files We provided all of our policies and procedures regarding data integrity and privacy right away We referenced sections of our narrative to discuss how we intend to use the data to evaluate the performance of ACO participants, and ACO providers/suppliers, to conduct quality assessment and improvement activities, and to conduct population-based activities to improve the health of your assigned beneficiary population. 31

Narratives Promoting Evidence Based Medicine Promoting Beneficiary Engagement Internally Reporting on Quality and Cost Metrics Promoting Care Coordination Each at least twenty pages long, some near forty pages Included a lot of attachments Diagrams of process Examples of engagement tools Examples of reports and data analysis Examples of coordination tools 32

Submission process Access to HPMS (Health Plan Management System) site needed Flows from NOI process HPMS site allows for review of NOI data Some is changeable, some is not Answer the attestation questions Simple clicks for yes or no Click the submit button to save File upload process Not connected to each question Compiled into larger zip file to be uploaded Only goes to CMS after Final Submit is completed 33

Application process general items Know the regulations, don t just respond to the application Electronic versus paper Tax ID concerns Get very familiar with Attachment D Reference Guide Assign a project manager Check website often https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/ Get help writing the narratives 34

Submission is only the beginning CMS is interested in having many succeed in the application process Requests for information should be expected Sent via email with letter to the key contacts 5 business days to respond Very specific instructions regarding reply 35