Transcript New Care Delivery Models - Indiana Continuity of Care

New Healthcare Delivery Models
Under the Patient Care and Affordability Act
Accountable Care Organizations
and Beyond
Robert W. Markette, Jr. CHC, JD
Benesch, Friedlander, Coplan & Aronoff, LLP
One American Square, Suite 2300
Indianapolis, IN 46242
Phone: (317) 632-3232
[email protected]
New Care Delivery Models
Center for Medicare & Medicaid Innovation
Accountable Care Organizations (“ACOs”)
Hospital Bundled Payments Pilot Program
Bundled Payments for Care Improvement
Independence at Home Project (“IAH”)
Initiative to Reduce Avoidable Hospitalizations among Nursing
Facility Residents
Community Based Care Transitions Program
Web site
http://innovations.cms.gov/
New Care Delivery Models
Goals:
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Reduce and control costs
Improve quality of care
Integrate and coordinate delivery of care
Deliver seamless, high quality care instead of the
fragmented care provide by FFS health care
These programs are likely to be
driven by large hospital systems
and/or physicians’ practices.
Accountable Care Organizations
PPACA required CMS to establish a
voluntary ACO program by January 1,
2012
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Promotes accountability for a patient population
Coordinates services under Medicare Parts A & B
Encourages investment in infrastructure and
redesigned processes for high quality and
performance standards
Accountable Care Organizations
CMS issued Final Rule on October 20, 2011
– established requirements for the
Medicare Shared Savings Program
(“MSSP”)
MSSP will reward ACOs that:
• Lower health care costs
• Meet performance standards on quality of
care
Accountable Care Organizations
Entities eligible to form an ACO:
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ACO professionals (physician, PA, NP, CNS) in a group practice
Networks of individual ACO professionals
Partnerships or joint ventures between hospitals and ACO
professionals
Hospitals employing ACO professionals
Critical Access Hospitals
Federally Qualified Health Centers
Rural Health Clinics
Other healthcare entities may provide services through an ACO
but not form their own and may not be used to assign patients to
the ACO.
Accountable Care Organizations
Formation
• Providers come together to form ACO
• Apply to CMS
• Must meet all eligibility and program
requirements
• Must serve 5,000 Medicare FFS patients
• Agree to participate in MSSP for 3 years
• An existing ACO will not automatically be
accepted
Accountable Care Organizations
ACO Requirements:
1. Be willing to become accountable for the
quality, cost, and overall care of assigned
beneficiaries
2. Enter into a three year agreement with
HHS
3. Have a formal legal structure to allow
receipt and distribution of payments
4. Include sufficient primary care providers
Accountable Care Organizations
5.
6.
7.
8.
9.
Have at least 5,000 Medicare FFS beneficiaries
assigned to it
Provide information to HHS to support the
assignment of beneficiaries to ACO
Have a leadership and management structure in
place
Define processes to promote evidence based
medicine, patient engagement, reporting on
quality and cost measures, and coordinating
care
Meet patient centeredness criteria
Accountable Care Organizations
An entity may be part of more than
one ACO, as long as its TIN is not one
that is used to assign beneficiaries.
Opens door for long-term care
facilities, home health agencies, and
hospice to be part of multiple ACOs.
Accountable Care Organizations
“Beneficiary Assignment” – operational term
needed to determine whether a beneficiary
received sufficient level of requisite services from
physicians in an ACO
• CMS will provide list of beneficiaries likely to receive care
from ACO based upon primary care utilization during most
recent period
• List will be updated quarterly based on current 12 month
period
• CMS will reconcile list to reflect beneficiaries who met
assignment criteria at the end of each performance year
Accountable Care Organizations
Medicare Beneficiaries
• Only beneficiaries in the traditional Medicare FFS
program under Parts A & B are eligible
• Participation in ACO is voluntary – no enrollment
• Medicare ACOs must notify patients they are
participating in an ACO – must post signs and
distribute notices
• ACOs can contact beneficiaries from CMS
prospective list to notify them of participation
and that ACO intends to request beneficiary’s
identifiable data from CMS
• 30 day wait period – if no response – ACOs can
obtain identifiable data
Accountable Care Organizations
Legal Structure
ACO must be a legal entity for:
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Receiving and distributing shared savings
Repaying shared losses
Provider compliance with quality criteria
Accountable Care Organizations
Governance
ACO must maintain an identifiable
governing body with authority to
execute functions of ACO
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2.
3.
Define processes to promote evidence-based
medicine and patient engagement
Report on quality and cost measures
Coordinate care
Accountable Care Organizations
At least 75% control of the ACO’s
governing body must be held by ACO
participants.
Each participant must have
proportionate control over governing
body decision making.
Must include one Medicare beneficiary
Accountable Care Organizations
Leadership and Management
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ACO managed by CEO/manager/general
partner – must be subject to control of governing
body
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Clinical management and oversight by seniorlevel medical director who is one of the ACO’s
physicians – must be regularly onsite at one of
ACO locations, board certified, and licensed in
a state where ACO operates
Accountable Care Organizations
Required Processes and Patient
Centeredness
ACOs are required to implement procedures
for the following:
1.
Promoting evidence based
medicine
2.
Promoting beneficiary engagement
3.
Internally reporting quality
and cost metrics
4.
Coordinating care
Accountable Care Organizations
Patient Centeredness
ACO must demonstrate patient
centeredness by:
1. Having a beneficiary experience of
care survey in place and describe
how the ACO will use the results to
improve care
2. Patient involvement in ACO
governance
Accountable Care Organizations
3. Process for evaluating health needs of
the ACO’s assigned populations
4. System in place to identify and update
high risk individuals must:
- promote improved outcomes
for high risk and multiple chronic
condition patients
- plan tailored to patients needs
Accountable Care Organizations
5. Have a mechanism in place for the
coordination of care (process to
when
exchange summary of care data
patient transitions)
Accountable Care Organizations
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7.
8.
A process to communicate clinical
knowledge/evidence based
medicine to beneficiaries in an
understandable way
Process for beneficiary
engagement/ shared decision
making
Written standards for access and
communication, including access to
records
Accountable Care Organizations
9.
10.
A process to measure clinical
performance by physicians
System in place to identify and
update high risk individuals
Accountable Care Organizations
MSSP – Methodology
• Providers and suppliers will continue to be
paid for services in the same manner
• ACO will be eligible to receive shared
savings payment if it meets quality
performance standards and has
generated shareable savings
Accountable Care Organizations
MSSP Track 1:
• Only shared savings in excess of
benchmark
• Sharing rate – up to 50%
• Not held accountable for losses
• Only in Track 1 for first agreement
period
Accountable Care Organizations
MSSP Track 2
• More experienced ACOs
• Will account for savings and losses
• Higher performance payment limit – 15% of applicable year’s
benchmark
• Higher sharing rate of up to 60%
• Share losses if per capita costs are above updated benchmark
by amount equal to or greater than MLR – set at flat 2%
• Liable for up to 60% of entire difference b/t updated benchmark
and actual expenditures for performance year
• Actual amount varies based on quality performance
• Rewards ACO with high quality score by reducing amount of
losses it owes to CMS
• Loss sharing limit
• 1st year loss = 5% of benchmark
• 2nd year = 7.5%
• 3rd year = 10%
Accountable Care Organizations
MSSP – Methodology – Step 1
• Establish benchmark at beginning of each
agreement period
• Benchmark surrogate measure of what
Medicare FFS Parts A & B expenditures would
have been in absence of ACO
• Initial benchmark is risk adjusted using the
CMS Hierarchical Condition Categories risk
adjustment model
• Trend benchmark forward to third year by
using national growth rate in Medicare Parts
A & B expenditures for FFS beneficiaries
Accountable Care Organizations
MSSP – Methodology – Step 1
• CMS will weight most recent year of benchmark
• Benchmark year 3 = 60%
• BY2 = 30%
• BY1 = 10%
• Allows CMS to establish lower Minimum Savings Rates
(“MSR”) & results in more accurate benchmark
• Each year CMS will update benchmark by projected
absolute amount of growth in national per capita
expenditures for Parts A & B
Accountable Care Organizations
MSSP – Methodology – Step 2
• Compare performance to benchmark to
determine shared savings/losses
• CMS will create MSR (2% to 3.9%) – accounts for
normal variation
• Track 1 – MSR accounts for normal variation
based upon # of assigned beneficiaries
• MSR creates a corridor around benchmark that must
be met or exceeded to share in savings
• If actual expenditures are lower than updated
benchmark and savings meet or exceed MSR, ACO will
be eligible for shared savings
Accountable Care Organizations
MSSP – Methodology – Step 2
• Track 2
• MSR – no requirement to be based on number of
assigned beneficiaries
• Minimum Loss Rate (“MLR”) is established to determine
if ACO is responsible for shared losses
• MSR & MLR set at flat 2%
• Lower MSR balances risk that ACO will achieve savings
• Actual expenditures must be lower than the updated
benchmark to be eligible for shared savings
• If actual expenditures are higher than the benchmark
and losses meet or exceed MLR, a loss is incurred = no
shared savings
Accountable Care Organizations
MSSP – Methodology – Step 3
• Determining sharing rate and shared
savings
• CMS will apply sharing rate, determined
for each ACO based on its quality
performance, to the difference between
the updated benchmark and actual
expenditures
• ACO will share in savings at this rate, on a
first $ basis up to performance payment
limit
MSSP – Methodology – Step 3
• Track 1:
• ACO may earn sharing rate up to 50%
• Performance payment limit = 10% of Part A &
B updated benchmark
• Track 2:
• May earn sharing rate up to 60%
• Performance payment limit = 15% of Part A &
B updated benchmark
Accountable Care Organizations
Quality and Continuous Improvement
CMS will define quality goals and
improvement goals for ACOs.
ACO must meet these goals to qualify for
shared savings.
Accountable Care Organizations
Quality Performance Scoring
33 measures from 4 “domains”
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Patient/Caregiver Experience of Care
Care coordination/Patient Safety
Preventative Health
At-Risk Population
Measures align w/ other CMS programs –
Physician Quality Reporting System, EHR
Incentive Programs, National Quality Strategy,
Million Hearts Initiative
Accountable Care Organizations
Patient/Caregiver Experience
• Getting timely care, appointments
& information
• Physician communication
• Patients’ rating of physician
• Access to specialists
• Health promotion & education
• Shared decision making
• Health status/functional status
Accountable Care Organizations
Care Coordination/Patient Safety
• Risk-standardized, all condition readmission
• Ambulatory sensitive conditions admissions –
COPD
• Ambulatory sensitive conditions admissions –
CHF
• Percent of PCPs who successfully qualify for
an EHR Incentive Program Payment
• Medication Reconciliation – after discharge
from an inpatient facility
• Screening for fall risk
Accountable Care Organizations
Preventative Health
• Influenza immunization
• Pneumococcal Vaccination
• Adult weight screening & follow-up
• Tobacco use assessment & cessation
intervention
• Depression screening
• Colorectal Cancer screening
• Mammography screening
• Proportion of adults who had their blood
pressure measured w/i preceding 2 yrs
Accountable Care Organizations
At Risk Population
• Diabetes
• Hemoglobin A1c control < 8%
• Blood pressure < 140/90
• Low density lipoprotein < 100
• Tobacco non-use
• Aspirin use
• Hemoglobin A1c poor control > 9%
Accountable Care Organizations
At Risk Population
• Hypertension
• Blood pressure control
• Ischemic vascular disease
• Complete lipid profile & LDL control < 100 mg/dl
• Use of aspirin or other antithrombotic
• Heart Failure
• Beta-blocker therapy for left ventricular systolic
dysfunction
Accountable Care Organizations
At Risk Population
• Coronary artery disease
• Drug therapy for lowering LDL cholesterol
• Angiotensin-converting inhibitor or
angiotensin receptor blocker therapy for
patients with CAD and diabetes and/or
left ventricular systolic dysfunction
Accountable Care Organizations
Quality Performance Scoring
• 1st performance yr – quality performance
standard = complete & accurate
reporting for all measures
• Subsequent yrs – quality performance will
be phased in - ACOs will be eventually
be assessed on performance
Accountable Care Organizations
Quality Performance Scoring
• Pay for Performance Phased In
• Yr 1 – pay for reporting all 33 measures
• Yr 2 – pay for performance = 25
measures – pay for reporting = 8
measures
• Yr 3 & beyond – pay for performance =
32 measures – pay for reporting = 1
measure
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
You will most likely not be starting an ACO.
You will need to be prepared to have a
relationship with ACO.
ACO will be a referral source.
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
Developing relationships:
1. Identify potential leaders in your area
2. Review existing relationships w/ hospitals and
physician groups that might be forming ACOs
3. Make sure you get a seat at the table
4. Show them what you can offer & how you can
add value
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
Key areas:
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3.
Quality – reduce rehospitalizations, improved
post-acute outcomes, patient satisfaction; etc.
Make sure you understand the quality measures
and how they might be used
Review your current policies/procedures related to
how you deal with post acute patients – update if
need to incorporate more quality goals
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
Key areas:
4.
Patient Centeredness –
communicating to patients, chronic
patient care, patient satisfaction
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
Key areas:
6.
Cost savings – getting patients out of
hospital and into post-acute care,
when done properly, saves
everyone money
Accountable Care Organizations
LTC Facilities, HHAs & Hospice
Providers that can make this case to ACO
leaders will be the ones that are included.
You will need to be proactive in making
your case.
Hospital Bundling
• Hospital centric model focused on an
episode starting three days prior to
admission and continuing for thirty days
post discharge.
• Built around the “entity”. Entity will have
a hospital plus post acute providers.
Hospital Bundling
• Payment methodology must not result in
greater expenditures per beneficiary.
• Payment shall be comprehensive and
cover the costs of applicable services
and other appropriate services.
• Services paid for by the pilot project shall
be provided or directed by the entity.
Hospital Bundling
Additional Post-Acute Care Services
Secretary to determine procedures for
providing additional post-acute care
services after the “episode.”
Hospital Bundling
HHS will develop quality measures for the
episode of care and for post-acute care.
Required measures:
functional status improvement;
reducing rates of avoidable hospital
readmissions;
Hospital Bundling
Required measures:
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Rates of discharge to the community
Rates of post hospitalization ER admission
Incidence of infection
Efficiency measures
Measures of patient centeredness
Measures of patient perception of care
Other measures including outcomes
Hospital Bundling
These required measures are
important to post-acute care
providers, because these are issues
hospitals are going to care about.
Start preparing now to make your
case around these measures.
Hospital Bundling
MAIN CONCERN: Hospital controls
payments
• This project looks at controlling costs by
placing hospital in charge of the money.
• Hospital will pay post acute providers.
• Project does not start until 2013.
Hospital Bundling
Preparing for hospital bundling will be a lot
Like preparing for ACOs.
1. Building relationship with hospital
2. Quality will be important
3. What you can do for the hospital
Hospital Bundling
Risk:
Will providers agree to lower rates to “get
Foot in the door?”
This might give larger agencies an
advantage.
Bundled Payments for Care Initiative
Propose – using a bundled model for
limited situations – heart attacks, hip
replacements, etc.
Initiative has 4 models.
Hospital Bundling
Interested entities can apply to
participate in one of the four models.
There are three retrospective models
and one prospective model.
Bundled Payments for Care Initiative
The models:
1.
Retrospective Acute Hospital Stay Only
2.
Retrospective Acute Care Hospital Stay plus
Post-Acute Care
3.
Retrospective Post Acute Care Only
4.
Acute Care Hospital Stay Only
Bundled Payments for Care Initiative
Post-acute care providers are eligible to
participate in Models 2 & 3.
Model 3 would allow post-acute care
provider to apply as the bundling entity.
Provider has to designate length of episode
– minimum of thirty days.
Provider has to designate amount of
discount to CMS.
Bundled Payments for Care Initiative
Model also requires entity to
designate eligible beneficiaries, by
MS-DRG and excluded unrelated
services.
NOTE: CMS will give preference to
applications that propose an episode
longer than thirty days.
Bundled Payments for Care Initiative
Gain sharing is allowed, but providers
are expected to provide evidence of
active participation by physicians and
other practitioners.
Bundled Payments for Care Initiative
Payment in this model:
Payment will be made under normal
PPS rules, with a regular
retrospective reconciliation against
the target price.
Bundled Payments for Care Initiative
Payment in this model:
If reconciliation shows the target
price was exceeded, the awardee
will be responsible for repaying
Medicare.
Bundled Payments for Care Initiative
Payment in this model:
IMPORTANT: The awardee “bears full
risk for any expenditures beyond the
target price of the episode.”
Bundled Payments for Care Initiative
Payment in this model:
If reconciliation shows the care was
delivered for less than the target
price, difference will be paid to the
awardee.
Bundled Payments for Care Initiative
Models 1 – 3 use a retrospective
reconciliation process.
Medicare pays, then compares
amounts paid to “target price.”
CMS is looking for “highly competitive”
discounts.
Bundled Payments for Care Initiative
Model 3 bundled payment will include
payment for Physician’s services,
inpatient hospital readmission; Long
Term Care hospital services, IRF
services, SNF services, HHA services,
outpatient therapy, lab services,
DME, and Part B Drugs.
Bundled Payments for Care Initiative
Model 3 creates potential to put postacute care providers in control of a
bundled payment.
Need to be able to figure out “target
price.”
Bundled Payments for Care Initiative
Awards are for an initial three year
period.
Possible to extend for an additional
two years.
CMS is considering appropriate
waivers of fraud and abuse laws in
order to allow this project to move
forward.
Bundled Payments for Care Initiative
RFA states specific requirements for gain sharing as
part of this bundling program.
Detail
How savings shared
Cannot reduce or limit medically necessary
services
Transparent and auditable
Physician participation is voluntary
Bundled Payments for Care Initiative
Gain sharing Payment methodology:
Not based upon volume or value
may not exceed 50% of amount
normally paid to physicians
comprehensive plan for distributing
awards
Independence at Home
• This is a physician/nurse practitioner pilot
project.
• Three year demonstration – covering not
more than 10,000 beneficiaries.
• Began in January, 2012.
Independence at Home
Project to test whether model which is
1. Accountable for providing
comprehensive, coordinated,
continuous, and accessible care to
high need populations at home
Can achieve certain goals.
Independence at Home
Goals:
1.
2.
3.
4.
5.
6.
7.
Reduce preventable hospitalizations
prevent hospital readmissions
reduce emergency room visits
improving health outcomes
improving efficiency of care
reducing costs
achieving beneficiary and family
satisfaction.
Independence at Home
Eligible patients must have:
Two or more chronic conditions
Two or more functional dependencies
At least one non-elective
hospitalization in prior 12 months.
Independence at Home
Chronic Conditions:
congestive heart failure
diabetes
COPD
ischemic heart disease
stroke
Alzheimer’s
others designated by Secretary
Independence at Home Medical Practice
Independence at Home Medical
Practice is the center piece of the IAH
project.
Remember: focus is on primary care at
home.
Independence at Home Medical Practice
“A legal entity that is comprised of an
individual physician or nurse practitioner
or group of physicians and NPs that
provides care as part of a team that
includes physicians, nurses, physician
assistants, pharmacists, and other health
and social services staff.”
Independence at Home Medical Practice
“Organized at least in part for purpose of
providing physician services;
Has documented experience in providing
home-based primary care to chronically
ill “high cost” beneficiaries;
At least 200 beneficiaries;
Uses technology;
Other defined criteria
Independence at Home Medical Practice
PPACA expressly allows for physician’s
assistants and nurse practitioners as long
as requirements of Act are met; NP or PA
practices consistent with state law; NP or
PA has requisite experience and training.
Independence at Home Medical Practice
IAH also allows for use of affiliated
providers, such as RNs and social workers.
By the IAH Medical Practice
Independence at Home – Cost Savings
Medicare will establish a spending target.
If entity provides care to patients for the
year for less than the target amount,
entity will receive portion of that saving
back as an incentive payment.
Independence at Home
Definitions do not appear to allow for home
health agencies as providers.
During open door telephone call, a number
Of providers asked CMS to include home
Health agencies.
Independence at Home and Home Health
Some thoughts:
At a minimum, IAH medical practice is
a
potential referral source.
Post-acute providers plays a role in
quality, avoiding hospitalizations,
etc.
Make that case to physicians.
Independence at Home and Home Health
Some thoughts:
Potential to establish a practice?
State regulatory issues.
Reimbursement issues.
May be a difficult road.
Independence at Home and Home Health
Some thoughts:
Long term: this is another step in
establishing the home as the place to
provide medical services. HHAs have
more experience in this area than any
other provider.
Initiative to Reduce Avoidable
Hospitalizations
CMS will partner with non-LTC facility,
independent organizations (enhanced care
& coordination providers “E&C Providers”) to
implement evidence-based interventions
that reduce avoidable hospitalizations for
LTC facilities’ residents.
Initiative to Reduce Avoidable
Hospitalizations
E&C Providers will:
• Collaborate w/ States & LTC facilities
• Implement intervention in at least 15 LTC facilities (can’t: have
>25% of residents In Medicare managed care, be hospitalbased, special focus facility, no outstanding IJ)
• Hire staff who are present at LTC facilities & work with LTC facility
staff to implement preventative services
• Work in cooperation with existing providers
• Facilitate residents’ transition from hospitals to nursing homes
• Provide support for improved communication & coordination
among existing providers
• Coordinate & improve management and monitoring of Rx
drugs
Initiative to Reduce Avoidable
Hospitalizations
• Will likely be one award per State
• E&C Providers that meet operational performance
parameters, are eligible to receive funds from the
Payment Management System on monthly basis
• Will be determined based upon a per facility fee
• E&C Providers cannot separately bill
Medicare/Medicaid for services at the facilities
• E&C Providers eligible for supplemental funds –
based on specific criteria related to:
• Reduction of hospitalizations
• Quality of care
• Minimal survey deficiencies
Initiative to Reduce Avoidable
Hospitalizations
• Awards per E&C Provider = $5 - $30
million
• Cover 4 yr agreement
• 7 awards
• Awards given by August 23, 2012
• Application process under way
Community-based Care Transitions
Program
• Community-based Organizations (“CBOs”)
will use care transition services to manage
Medicare patients’ transition from hospital to
post-acute care providers
• Will be paid all inclusive rate per eligible
discharge based on the cost of the transition
services provided at the patient level and
implementing changes at the hospital level
• Transition services must be provided across
the continuum of care
• Must have formal relationship w/ hospitals
and other providers along continuum
Community-based Care Transitions
Program
• CBO must be present in community it
serves
• Must be legal entity that can accept
payment for services
• Must have governing body w/
healthcare stakeholders and consumers
• Program will run 5 yrs
• Application process under way
Conclusion
PPACA contains several new care delivery
methods that will impact home health and
hospice
Providers need to be prepared to make
their case to these entities in order to be
part of the future.
Conclusion
Focus will be on:
Quality – reducing hospitalizations
Efficiency – doing more for less
Cost Savings
New Healthcare Delivery Models
Under the PPACA
Legal Disclaimer:
The materials and opinions presented by the speaker
at this session represent the speaker’s views, are for
educational and informational purposes only, are not
intended to be legal advice and should not be used
for legal guidance or to resolve specific legal
problems. The speaker expressly reserves the right to
advocate other positions on behalf of clients. In all
cases, legal advice applicable to your organization’s
own specific circumstances should be sought.