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Clinical Integration:CMI
BUNDLED PAYMENTVALUE-BASED PURCHASING
andACOs
Presented by:
Michele Madison Partner, Healthcare & Healthcare IT Practices
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Session Objectives
Discuss the Centers for Medicare and Medicaid Innovation
Bundled Payments and the Models
Partnership for Patients
Value Based Purchasing
ACOs
Clinical Quality and Integration
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CMI
• Creation of Centers for Medicare and Medicaid Innovation (CMI).
• The CMI will be the major focal point for the identification of problem areas in health care delivery and identification and testing of new models to improve program performance.
• To design, implement and evaluate Medicare and Medicaid demonstrations and pilot programs to test the feasibility, cost effectiveness and quality outcomes of new health care delivery models.
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CMI Cont’d
• To promote research and demonstration transparency by disseminating findings to inform law makers and interested parties about health care delivery issues, new innovative concepts, and demonstrations and pilot programs.
• Evaluative findings to develop new objectives for basic research and new research demonstrations.
• Has the authority to extend and expand the operation of successful models.
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Bundled Payments
1. Episode of care as the acute care hospital stay only (Model 1),
2. The acute care hospital stay plus post-acute care associated with the stay (Model 2),
3. Just the post-acute care, beginning with the initiation of post-acute care services after discharge from an acute inpatient stay (Model 3).
4. A single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians and other practitioners.
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Partnership for Patients
A new public-private partnership that will help improve the quality, safety and affordability of health care for all Americans.
The Partnership for Patients has the potential to save up to $35 billion in U.S. health care costs, including up to $10 billion for Medicare
$500 million in funds to test different models for improving patient care and patient engagement to reduce hospital-acquired conditions and improve care transitions
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Partnership for Patients
Goals:
Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.
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Value Based Purchasing
Hospitals will be scored based on their performance on each measure relative to other hospitals and on how their performance on each measure has improved over time.
The higher of these scores on each measure will be used in determining incentive payments
The Fund is taken from a 1% decrease in Medicare reimbursement and is estimated t be $850Million in the first year 2013
ACONew Model of Delivery
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What is an ACO?
Accountable care organization (ACO)
• Means a legal entity that is recognized and authorized under applicable State law;
• Identified by a Taxpayer Identification Number (TIN);
• Comprised of an eligible group of ACO participants that work together to manage and coordinate care for Medicare FFS beneficiaries; and
• Have established a mechanism for shared governance that provides all ACO participants with an appropriate proportionate control over the ACO's decision making process.
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Statutory Basis
• Shared Savings Program is part of the Patient Protection and Affordable Care Act to be codified at 42 USC 1899.
• It is not a demonstration program. It is part of the Statute and the effective date is January 1, 2012.
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Impact on Healthcare
• Coordinates the delivery of care between providers.
• Encourages investment in infrastructure (Healthcare IT).
• Encourages the redesign of care processes to focus upon quality and efficiencies.
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Basic Requirements
1. Accountable for the quality, cost, and the overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.
2. Enter into an agreement with the Secretary to participate in the program for not less than a 3-year period.
3. Formal legal structure that would allow the organization to receive and distribute payments for shared savings to participating providers of services and suppliers.
4. Include primary care professionals that are sufficient for the number of Medicare FFS beneficiaries assigned to the ACO. (At least 5000 beneficiaries).
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Basic Requirements
5. Provide the Secretary with such information regarding ACO professionals participating in the ACO as the Secretary determines necessary to support the assignment of Medicare fee-for-service beneficiaries to an ACO, the implementation of quality and other reporting requirements, and the determination of payments for shared savings.
6. Maintain leadership and management structure that includes clinical and administrative systems.
7. Define processes to promote evidence-based medicine and patient engagement.
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Basic Requirements
8. Report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.
9. Demonstrate to the Secretary that the ACO meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.
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Eligible Entities
• 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.
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Eligible Entities
Limits and excludes some key areas of the healthcare delivery system:
– FQHC
– RHC
– CAH
Secretary has the discretion to include some of these providers.
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Legal Entity/Governance
• Recognized under State Law as Legal Entity with a TIN.
• Governing Body must have 75% representation from ACO members.
• Financial and clinical Integration.
• A leadership and management structure that includes clinical and administrative systems.
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Assignment of Beneficiaries
• Assigned based on “plurality” of primary care services with a PCP in an ACO.
– Based on allowed charges, not a simple count of services.
• Assigned retrospectively for calculating savings.
– CMS will provide list of beneficiaries.
PCPs can only participate in 1 ACO.
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Eligibility: Required Processes
• The ACO application will require the applicant to describe its plans for:
• Processes to promote evidence-based medicine
• “…the application of the best available evidence gained from the scientific method to clinical decision-making.”
• The establishment and implementation of evidence-based guidelines, based on the best available evidence concerning the effectiveness of medical treatments, at the organizational or institutional level; plus
• Regular assessment and updating of guidelines to promote continuous improvement in the quality of care in light of new evidence concerning the effectiveness of medical treatments.
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Eligibility: Required Processes
• Processes to promote patient engagement
• “…the active participation of patients and their families in the process of making medical decisions.”
• The opportunity for patients and families to assess prospective treatment approaches in the light of their own values and convictions.
• Also includes methods for promoting "health literacy" in patients and their families, including basic knowledge about maintaining good health, avoiding preventable medical conditions, managing existing conditions, and knowledge about how the care system works.
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Eligibility: Required Processes
• Processes to report on quality and cost measures
• Such as developing a population health data management capability, or implementing practice and physician level data capabilities with point-of-service (POS) reminder systems to drive improvement in quality and cost outcomes.
• ACOs expected to be able to monitor both costs and quality internally and make appropriate modifications based upon their collection of such information.
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Eligibility: Required Processes
• Processes to promote coordination of care
• Strategies to promote, improve, and assess integration and consistency of care across primary care physicians, specialists, and acute and post-acute providers and suppliers.
• Includes methods to manage care throughout an episode of care and during its transitions (i.e. discharge from a hospital or transfer of care from a primary care physician to a specialist).
• May include such strategies as predictive modeling to anticipate likely care needs; case managers in primary care offices; specific transition of care programs that include guidance and instructions for patients, their families, and their caregivers; remote monitoring; telehealth; and the use of health information technology to transfer patient care information in transitions.
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Eligibility Requirements:Patient Centeredness Criteria
• An ACO must be able to show that it meets specified patient-centeredness criteria.
• “…care that incorporates the values (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care. Patient-centered care should extend not only to the patient but to the family and caregivers of the patient.”
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Eligibility Requirements:Patient Centeredness Criteria
• 8 required criteria
1. Patient experience of care survey.
2. Patient involvement in governance of the ACO.
3. Evaluation of population health needs and consideration of diversity in patient population.
4. Systems to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations, including integration of community resources.
5. Mechanisms for the coordination of care.
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Eligibility Requirements:Patient Centeredness Criteria
• 8 required criteria (continued)
6. Processes for communicating clinical knowledge/evidence-based medicine to patients.
7. Patient access and communication and a process in place for patients to access their medical record.
8. Internal processes for measuring clinical or service performance by physicians across the practices, using these results to improve care and service.
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Quality and Other Reporting Requirements
• Three stated goals for improvement of the health care of Medicare beneficiaries and, by extension, of all Americans.
1. Better care for individuals;
2. Better health for populations; and
3. Lower growth in expenditures.
• “Better health care for individuals” defined as health care that is safe, effective, patient-centered, timely, efficient, and equitable.
• The Quality Performance Standards sections of the proposed rule relate to the first two goals.
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Quality Performance Standards
• The Proposed Regulations specify 65 measures (see Table 1 in the Regs) based on the aims of improved care and improved health. Each measure has NQF endorsement or is currently used in other CMS quality programs.
• Improved Care measures are organized in three domains:
• Patient/caregiver experience (7 measures, all based on survey results);
• Care coordination (16 measures, including percentage of ACO participants that meet HITECH meaningful use requirements);
• Patient safety (2 measures).
• Improved Health measures are organized in two domains:
• Preventive health (9 measures) and
• At-risk populations/frail elderly (29 measures, including diabetes (10 measures); heart failure (7 measures); coronary artery disease (5 measures); hypertension (2 measures); COPD (3 measures); and frail elderly (2 measures)).
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Quality Performance Standards
[Excerpt from Table 1 of the Proposed Regulations]
Domain
Measure Title & Description
CMS Program, NQF Measure Number, Measure Steward
Method of Data
Submission
Measure Type
AIM: Better Care for Individuals
1Patient/Care Giver Experience
Clinician/Group CAHPS: Getting Timely Care, Appointments, and Information NQF #5 Survey
Patient Experience of Care
2Patient/Care Giver Experience
Clinician/Group CAHPS: How Well Your Doctors Communicate NQF #5 Survey
Patient Experience of Care
3Patient/Care GiverExperience
Clinician/Group CAHPS: Helpful, Courteous, Respectful Office Staff NQF #5 Survey
Patient Experience of Care
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Quality Measures Data Collection
• Data collection and submission methods:
• Most performance measures can be derived from CMS data.
• Many of the measures are based on data similar to that collected for other purposes, such as the Physician Quality Reporting System, EHR Incentive Program, etc.
• For quality data not captured in claims processing systems, CMS will make available a CMS-specified data collection tool (see measures designated for Group Practice Reporting Option (GPRO) Data Collection Tool in Table 1.
• Some measures specify the use of patient survey instruments.
• For future program years, certified EHR technology may serve as additional measures reporting mechanism.
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Antitrust Policy Statement
• ACO must determine its expected market share in each ACO participant’s primary service area (referred to as “PSA Shares”) for specific health care services, based on Medicare claims data.
• If (a) the combined PSA Shares for two or more participants does not exceed 30 percent, and (b) none of the ACO’s hospitals or ASCs are exclusive to that ACO, the ACO will qualify for the antitrust safety zone. The ACO will not be subject to antitrust challenge absent extraordinary circumstances. Special rules apply if ACO participants include a “dominant provider” or a certain number of rural hospitals or physicians.
• If the combined PSA Shares for any two or more participants in the ACO exceeds 50 percent, the ACO must apply for expedited (90 day) antitrust clearance prior to applying to CMS. Without such clearance, the ACO is not eligible for the Program.
• If an ACO has a PSA Share between 31 and 50 percent, that ACO has the option of requesting clearance from the antitrust agencies. An ACO that voluntarily seeks antitrust clearance runs the risk of being barred from the Program if the antitrust agencies deny the request.
• Once an ACO receives antitrust clearance from the antitrust agencies and is approved for the Program, the ACO participants also may negotiate jointly with private insurance companies ( i.e., enter into single signature contracts, as opposed to utilization of the messenger model).
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Future of Payment Models
• Linking payment to quality.
• Enhanced quality reporting for physicians and hospitals.
• Be ready for HIPAA 5010 and ICD-10.
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Thank You for Joining Us Today
Please contact any of our presenters after the presentation if you have additional questions:
Michele Madison Partner, Healthcare & Healthcare IT Practices404.504.7621 / [email protected]
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Disclaimer
The materials and information presented and contained within this document are provided by MMM as general information only, and do not, and are not intended to constitute legal advice.
Any opinions expressed within this document are solely the opinion of the individual author(s) and may not reflect the opinions of MMM, individual attorneys, or personnel, or the opinions of MMM clients.
The materials and information are for the sole use of their recipient and should not be distributed or repurposed without the approval of the individual author(s) and Morris, Manning & Martin LLP.
This document is Copyright ©2011 Morris, Manning & Martin, LLP. All Rights Reserved worldwide.
