Responding to the Proposed ACO Rule: Positions, Insight and Guidance - - PowerPoint PPT Presentation

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Responding to the Proposed ACO Rule: Positions, Insight and Guidance for PPS Members

Accountable Care Organizations

Medicare Shared Savings Program

Draft Comments on Proposed Rule

Private Practice Section APTA

Jerry Connolly Connolly Strategies & Initiatives connollystrategies@gmail.com 703-307-5363

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Themes in Health Care Reform

• Prevention and wellness, Medicaid expansion,

exchanges, nondiscrimination

Expansion of Coverage

• Cuts in payment rates, refinements to payment

systems, patient assessment instruments

Refining / Changing Payment Methodologies

• Value based purchasing, hospital readmissions

policy, electronic health records, registries

Linking Payment to Quality

• Provider Enrollment
• Funding Increases for Enforcement
• Expansion of Audits (RACs)

Program Integrity

• Bundling
• Accountable Care Organizations
• Medical Homes

Integrated Models of Care – Innovation

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Accountable Care Organizations

 Labeled the Medicare Shared Savings Program  Shared savings for

• hospitals and doctors
• changing payment models from FFS
• to model that rewards efficiency and quality
• (from fragmentation to coordination)
• (from volume to value)

 Implementation date: 1/1/2012—this is not a pilot!  Viewed as a potential means for bending the health care cost curve  CBO scored 10-year savings of $4.9 billion

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Proposed Rulemaking for ACOs

Medicare Shared Savings

 Sec. 3022 of the Affordable Care Act requires CMS to establish a Medicare Shared Savings program “by Jan. 1, 2012 that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.” Participating entities, referred to as Accountable Care Organizations that meet quality and performance standards are eligible to receive payments for shared savings.

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Purpose of Today’s Webinar

Review DRAFT comments to the rule Provide specific suggestions for comment Provide education and generate discussion Encourage PPS members to comment

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Questions from 1st Webinar

 Can a PTPP join more than one ACO?  Is there a limit to the amount of ACOs a PT practice can partner with? (e.g. 1 PT in 5 ACOs)  Is there a limit to the amount of PTs an ACO can partner with? (e.g. 5 PT’s in 1 ACO) What protections are there for the independent practitioners to be a part of the solution? Will an independent provider be able to share in cost savings if they are integral in making the ACO successful?

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Questions from 1st Webinar

 How will CMS monitor antitrust activities to insure that subscribers have an opportunity to go to a non ACO participant?  If a subscriber to an ACO receives care outside their “approved provider” network, will that subscriber be scrutinized by the ACO for leaving their delivery system? How will this be prevented? Will the ACO be able to positively steer a subscriber to one of their providers and away from a patient choice? Will they be able to pressure subscribers?

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Questions from 1st Webinar

With respect to shared savings, what exactly they are comparing in regards to the cost, i.e., are they looking at this based on cost per diagnosis code vs overall cost per beneficiary in a given calendar year? Is this factored per patient or by an overall average of patients with that diagnosis? Are they looking at average cost per diagnosis code and then factoring in additional diagnosis codes, co-morbidities, etc.?

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Questions from 1st Webinar

Since a Medicare subscriber can go to any provider within the ACO system or outside the ACO system, what benefit is there to being a part of the ACO?

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ACO -- Rulemaking

Regs promulgated in four separate rulemakings:

• CMS Medicare Shared Savings Program Proposed

Rule:

http://www.ofr.gov/(X(1)S(xrkl4mdtyvi54lavhney5kfi))/OFRUpload/OF RData/2011-07880_PI.pdf

• CMS/OIG Waiver of Fraud and Abuse Certain

Provisions Notice with Comment Period:

http://www.ofr.gov/(X(1)S(vxlliaunmjoofe4qc13ybxl1))/OFRUpload/OFRDa ta/2011-07884_PI.pdf

• FTC/DOJ Anti-trust Enforcement Policy Notice with

Comment Period:

http://www.ftc.gov/os/fedreg/2011/03/110331acofrn.pdf

• IRS Request for Information on Tax-Exempt Status

for Shared Savings Programs: http://www.irs.gov/pub/irs-

drop/n-11-20.pdf

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Background

Providers of services and suppliers were listed in that Statute as eligible to participate: ACO professionals in group practice arrangements. Networks of individual practices of ACO professionals. Partnerships or joint venture arrangements between hospitals and ACO professionals. Hospitals employing ACO professionals. Such other groups of providers of services and suppliers as the Secretary determines appropriate.

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Background/Comment

PPS/APTA is pleased that the proposed rule recognizes the ability of PPPTs to participate in ACOs through the establishment of the category of “ACO Participant.”

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Definition

An ACO is defined as a group of health care providers accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to the organization. It must meet specified quality performance standards to receive a share of any savings individual practices of ACO professionals. Partnerships or joint venture arrangements between hospitals and ACO professionals. Hospitals employing ACO professionals. Such other groups of providers of services and suppliers as the Secretary determines appropriate.

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Definition/Comment

PPS/APTA is generally supportive of any program that rewards high-quality, cost- effective care. However, a number of concerns that could result in a negative impact on independent providers who

• perate as small businesses and the patients

they serve.

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Structure

Application and approval process. ACO may be a corp, partnership, LLC, foundation, etc. Appropriate proportionate control by ACO participants. Medicare patient and ACO providers on board ACO participants must have at least 75% control Allows for partnering with private entities Must do evidence-based medicine or clinical guidelines Serve Triple Aim [better care, better health, lower cost] Participation voluntary for providers and patients. ACOs must notify patients that

• they are a part of an ACO and
• health information will be shared among ACO

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Structure / Comment

Financial/clinical integration implications?

• Participating in >1 ACO

What assurance inducement not permitted Private entity contracting loophole

• Unqualified workers not allowed in patient

care

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Leadership & Management

Infrastructure Senior-level medical director Commitment to clinical integration Health information technology Feedback to providers/participants QA/CI programs described Adherence to EBM/clinical guidelines

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L & M Comment

HIT resources lacking – disadvantage PTs De facto disqualification? Inclusion safeguards for nonphysicians

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Governing Body

75% participant control Partner with community stakeholders Partner with Medicare FFS beneficiaries

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Governing Body/ Comment

75% participant control Partner with community stakeholders

Who are stakeholders? Should include PPPTs

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Sufficient Number of PCPs

Serve 5000 Medicare FFS patients PCPs must have EHR by Yr 2 Report list of providers/ participants annually

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Sufficient Number of PCPs/Comment

Must have sufficient number, type, and location of providers for necessary care Beneficiary assignment retroactive

• Problematic
• Can’t project savings
• Implications for business plan
• Operating capital

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Beneficiary Info and Notice

CMS communications plan

• Shared savings
• Utilization of service
• Possibility of beneficiary assignment

ACO communication

• Participating in Medicare Shared Savings

Program

• Written notice to beneficiaries
• Sharing of health information – request for

authorization

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Beneficiary Info and Notice/Comment

ACO communication should be strengthened

• Patient should sign notice that has been

informed of right to receive care from provider

• f their choice

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Quality and Monitoring

Physician-directed QA committee Quarterly & annual reports – 5 domains

• Patient/caregiver experience
• Care coordination
• Patient safety
• Preventive health, and
• At-risk population/frail elderly health

PQRS measures (year 1)

• Reported by ACO (GPRO)
• Greater reporting – greater eligibility for shared

savings

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Quality and Monitoring/ Comment

Add 6th quality domain

• Patient’s functional status
• Consistent with Triple Aim = better health
• Functional status should be emphasized

PQRS measures (year 1) Year 2 & 3 unknown but used to determine savings Reported by ACO (GPRO) confusing/complex

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Quality and Monitoring/ Comment (2)

ACO incentivizes efficiency Utilization control regs unnecessary

• Three-day hospital stay before SNF
• F2F before HHA
• Therapy caps
• Referral (POC) requirement

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EBM; Patient Engagement; Care Coordination

 ACO shall provide documentation

• Promote EBM
• Promote beneficiary engagement
• Report internally on quality/cost
• Coordinate care

 Allow ACO flexibility

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EBM; Patient Engagement; Care Coordination

Comment

 ACO shall provide documentation . . .

• Place greater emphasis on functional status
• Consistent with “Triple Aim”

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EBM; Patient Engagement; Care Coordination (2)

 Transitions in care among providers supported by HIT to improve coordination

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EBM; Patient Engagement; Care Coordination (2) Comment

 All providers must be “connected”  This will require interoperability of EHRs;

• not yet a reality

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EBM; Patient Engagement; Care Coordination (3)

The ACO shall not impede the beneficiary’s ability to seek care from providers that are not participating in the ACO or develop policies to place any restrictions that are not legally required on the exchange of medical records with providers who are not part of the ACO. Therefore, CMS proposes to prohibit the ACO from developing any policies that would restrict a beneficiary’s freedom to seek care from providers and suppliers outside of the ACO.

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EBM; Patient Engagement; Care Coordination

Comment

Re-emphasize:  Beneficiary’s freedom of choice of provider should not be impeded in any way. PPS/APTA calls upon CMS to strictly and vigorously enforce this provision.

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Public Reporting

CMS proposes that certain information regarding the ACO and ACO participants be publicly reported including:

• shared savings or shared losses
• proportion distributed to ACO participants
• quality performance standard scores

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Public Reporting/ Comment

We concur with this proposal but urge CMS, at least in the early years of the Medicare Shared Savings Program allow verification of any data by the ACO prior to public reporting.

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Beneficiary Assignment To Calculate Eligibility for Shared Savings

ACO will have an assigned population of beneficiaries;

• retrospective beneficiary assignment to

determine eligibility for shared savings

• aggregate beneficiary level data for the

assigned population of Medicare beneficiaries during the benchmark period.

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Beneficiary Assignment … Shared Savings

Comment

Retroactive assignment of beneficiaries to the ACO is problematic. Without knowing in advance the prescribed population and its characteristics, the ACO is not in a position to write a defensible business plan and thus could experience difficulty in acquiring the necessary startup capital.

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Proposed Shared Savings

Minimum savings rate (2.0 – 3.9%) based on a percentage of the benchmark that the ACO must

• exceed. And 25% of the ACO shared savings payments

will be withheld (ensure against losses ) One-Sided Risk Model—Savings are shared for the first two years and then in the third year savings and losses are shared (the sharing rate is 50%) Two-Sided Risk Model—Savings and losses are shared for all three years (the sharing rate is 60%) Shared savings payments made directly to ACO

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Proposed Shared Savings / Comment

Given the initial capital requirements estimated by CMS and in the absence of hard experiential data, we wonder if the above described shared savings formula will provide sufficient return on investment.

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ACO Marketing Guidelines

CMS concerned about accuracy and consistency

• f communications that will be sent to the

provider regarding their participation in the ACO and confusion that the ACO is likened to managed care. All ACO marketing materials, communications, and activities related to the ACO and its participation in the Shared Savings Program that are used to educate, solicit, notify or contact beneficiaries or providers regarding ACO participation be pre-approved by CMS

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ACO Marketing /Comment

Clear consistent communications important. However, we wonder if CMS has the resources to review and approve marketing materials in a timely manner.

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Program Integrity Requirements

ACOs must have a compliance plan on how it plans to meet the applicable legal requirements. ACO must have a conflict of interest policy that applies to members of the governing body. To mitigate cost shifting in the Medicare program to patients outside of ACOs, CMS proposes to prohibit ACOs and its participants from conditioning participation in the in the ACO

• n referrals of Federal health care program

business

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Program Integrity Requirements/ Comment

Providers may be participating in an ACO for some patients, but continuing to function as an independent provider for others. Attempting to meet legal requirements of two or more entities can create confusion. We are unclear as to how “prohibiting ACOs and the participants from conditioning participation in the ACO on referrals of Federal health care program business that the ACO or its ACO participants know or should know is being provided to beneficiaries who are not assigned to the ACO” will successfully mitigate cost shifting in the Medicare program to patients outside of ACOs.

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Alignment With Other Federal Laws

In order to allow providers and suppliers who heretofore may have been competitors to

• rganize and share revenues, CMS and the OIG

propose to waive certain provisions of the Stark II statute, Anti-kickback statute, and CMPs for ACOs and participants who meet the Shared Savings Program requirements. Moreover, the Federal Trade Commission (FTC) and the Department of Justice (DOJ) will monitor market share and market dominance in any given area.

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Alignment With Other Federal Laws / Comment

PPS/APTA is concerned that such waivers could enable, and in fact encourage such

• verutilization behavior DURING participation in

an ACO if the reward or penalty is not more appealing than the self-referral behavior. Secondly, providers who are no longer participating in an ACO will have the benefit of knowing other providers’ proprietary financial data that can be used inappropriately in certain markets AFTER participation in the ACO has ceased.

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Alignment With Other Federal Laws / Comment

(2)

We are very concerned that CMS is proposing to allow waivers to allow distributions of shared savings to providers not formally affiliated with the ACO for “activities necessary for” and “directly related to” ACO operations. Allowing such transactions is fostering “pay-to-play” and kickbacks that will be detrimental to the Medicare program and the beneficiary. Such damage could permeate the nongovernmental programs by allowing the waivers to extend to shared savings from private payers.

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Regulatory Timeline

Comments are due by June 6, 2011 Final rules published later this year ACOs must be operational by January 2012 Demonstrations will also take place in concert with ACO implementation and will be run through CMMI (separate & apart from this rule) Another option announced May 17 – startup $$

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PPS Next Steps

Continue analysis, summarize, identify impact Member feedback welcome Draft comments to proposed rules Share with membership (webinar, talking points) Develop strategies -- e.g., guidelines, resources and models that articulate the VALUE of physical therapists (PTPPs) Member education and outreach

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Thank You!

Medicare Shared Savings Program ACOs Draft Comments on Proposed Rule

Private Practice Section APTA Jerry Connolly Connolly Strategies & Initiatives connollystrategies@gmail.com 703-307-5363

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Questions/Discussion

? ? ACOs ? ?

OUTCOMES

Co/APTA PPS/SIG Agenda Effectiveness

Health Care Reform Value

Efficiency

Know Your Costs

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Negotiation

HMO versus ACO

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• Insurer-owned
• HMO assigns physician(s)
• Restricted access
• Decisions made by health plan
• Physician is protector of insurance

dollars

• Health information controlled by

insurer

• Care based on cost
• Every patient has a gatekeeper
• Capitated payment
• Shareholder centric
• Defaults to underutilization
• Managed cost; emphasis on profits
• Patient victimized by plan policy &

bureaucracy

• Rewards payer for less care
• Provider-owned
• Patient selects physicians
• Open access
• Decisions made by health professionals
• Physician’s role is coordination and

advocacy

• Health information coordinated by

physicians

• Care based on need; clinical guidelines
• Every patient has personal physician
• FFS + bonus
• Patient centric
• Fosters proper utilization/coordination
• Coordinated care; emphasis on patients
• ACO and personal physician are patient

advocates

• Rewards patient-centered, effective care