aco - ed white - ppt.pptx [read-only]€¦ · clinical and administrative information 31. appendix...
TRANSCRIPT
![Page 1: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/1.jpg)
Accountable Care Organizations: Lessons Learned from the ACOLessons Learned from the ACO
Process and ApplicationsPresentation to
South Carolina Hospital AssociationC OCFO Forum
The Sea Pines ResortThe Sea Pines ResortHilton Head, SC
August 28 2013August 28, 2013Edward K. White
Nelson Mullins Riley & Scarborough LLP1320 Main Street, 17th Floor
Columbia, SC 29201
1
[email protected]‐255‐9559
Doc. 4817‐2036‐8917
![Page 2: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/2.jpg)
What is an ACO?
An ACO is a collaboration of physicians and other health care providers to coordinate patient care.
Monitors quality and cost.
Eligible to receive additional payments for achieving quality and cost savings goals.g g
Reimbursement vehicle.
22
![Page 3: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/3.jpg)
The ACO Concept
PCP M di & O h P
$ Shared Savings
Hospital PCP Groups
Multi‐
Medicare & Other Payors
Specialist Groups
MultiSpecialty Groups
Bundled or CapitatedPayments
Other Providers Other Providers Mental Health
Home Health Long Term Care / Hospice
ACO
33
![Page 4: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/4.jpg)
ACO Reimbursement Reform Transition from Fee For ServiceFee‐For‐ServiceMedicare Shared Savings Program – started January 1, 2012
Expected changes: Bundled Payments / Episodes of Care Bundled Payments / Episodes of Care Global Payment / Partial Capitation
44
![Page 5: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/5.jpg)
Results of First Year of Pioneer ACO Initiative
All 32 participants improved the quality of patient care and rated high on patient satisfaction
25 of 32 participants reduced hospital readmissions against benchmarksbenchmarks
18 achieved cost savings but only 13 saved enough to share g y gsavings with Medicare• 13 received $76 million in savings
55
![Page 6: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/6.jpg)
Results of First Year of Pioneer ACO Initiative (cont.)
2 of the 32 will owe Medicare $4 million
Pioneer ACOs combined for $140 million in total savings and $52.4 million in total losses
9 of the 32 are switching to the shared savings ACO program
66
![Page 7: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/7.jpg)
Lessons for Pioneer ACOs
1. Manage expectations – it takes time to develop the culture, process and capabilities to coordinate care to hi i ifi t t d tiachieve significant cost reductions.
2 Importance of Interoperability – ACOs experienced2. Importance of Interoperability ACOs experienced problems with lack of IT interoperability, need for functionality to comply with meaningful use requirements d i i dand varying connection speeds.
• EHR systems have to be able to trade information with all other software systemswith all other software systems
77
![Page 8: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/8.jpg)
Lessons for Pioneer ACOs (cont.)
3. Be Realistic with Capabilities – Some of Pioneer ACOs may have overestimated their capabilities relative to their fi i l i kfinancial risks.
4 Big Picture – Pioneer ACOs appear to be doing a good job4. Big Picture Pioneer ACOs appear to be doing a good job at increasing patient satisfaction and bending the cost curve.
88
![Page 9: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/9.jpg)
Why Participate in an ACO When:
1. You are working to reduce your core revenue system
2. Incentives are not likely to be adequate to cover lost revenues
99
![Page 10: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/10.jpg)
Considerations Why You Should Participate:
1. Inevitable that change to eliminate inefficiencies will continue
2. Shift from fee for services to at‐risks payments will occur
3. Lost revenue from eliminating inefficiencies will have to be made up through increasing market sharep g g
1010
![Page 11: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/11.jpg)
Considerations Why You Should Participate (cont.)
4. Providers best able to coordinate care with highest quality and lowest cost will be best equipped to transition to at‐i k trisk payments
5 Opportunity to help physicians on your medical staff5. Opportunity to help physicians on your medical staff supplement their incomes
1111
![Page 12: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/12.jpg)
Lessons Learned
Application Process:1. Reference ACO Toolkit while completing application.
2. ACO Participation Agreements must be in place prior to s bmitting an applicationsubmitting an application.
3 ACO participants must have at least 75% control of the3. ACO participants must have at least 75% control of the governing body.
1212
![Page 13: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/13.jpg)
Lessons Learned (cont.)
4. Taxpayer Identification Numbers (TINs) are collected for all ACO participants.
• ACO participant TIN upon which beneficiary assignment is based is exclusive to one ACO
• Plurality of primary codes determines beneficiary• Plurality of primary codes determines beneficiary assignment to an ACO
• Primary care practices will be exclusive to an ACO• One physician in a group can attribute entire group
because group TIN determines exclusivityS i li t ld b i d t b l i if• Specialists could be required to be exclusive if providing primary care codes
1313
![Page 14: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/14.jpg)
Lessons Learned (cont.)
5. Pay close attention to regulations as they relate to legal structure, governing body and agreement with ACO and
ti i tparticipants.
6 Required Medicare beneficiary on the governing board may6. Required Medicare beneficiary on the governing board may not be an ACO participant.
1414
![Page 15: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/15.jpg)
Lessons Learned (cont.)
7. Specifically address your ACO's remedial process if a participant is non‐compliant with the ACO requirements.
8. If you answer "yes" to the question, "whether you jointly negotiate contracts with private payors" then CMS willnegotiate contracts with private payors , then CMS will share your information with FTC and DOJ.
1515
![Page 16: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/16.jpg)
Lessons Learned (cont.)
Structural Considerations:1. Most ACOs are being formed as LLCs.
2. Most ACOs will likely not apply for tax‐exempt status.• IRS applying rigid views of tax exemption and not
clear how it will apply standards• Tax‐exempt ACO will need to be nonprofitTax exempt ACO will need to be nonprofit
corporation. Private parties generally prefer LLC taxed as a partnership
1616
![Page 17: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/17.jpg)
Lessons Learned (cont.)
3. Governance is not required to be tied to ownership.• Reserved powers can be used to alter control
4. Leadership is the key to the ACOs success and ACOs will need attention of the leaders selectedneed attention of the leaders selected.
1717
![Page 18: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/18.jpg)
Lessons Learned (cont.)
Operational:1. Compliance Plan is required.
• Compliance officer is a required position
22. Waivers – ACOs granted waivers from Anti‐kickback, Stark and CMP. Only apply operations within ACO.• Start‐up Waiver – one party can disproportionatelyStart up Waiver one party can disproportionately
fund ACO start‐up costs but make sure not funding broader initiatives for physician, e.g., electronic health
d t id f ACOrecords outside of ACO
1818
![Page 19: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/19.jpg)
Lessons Learned (cont.)
2. Waivers (cont.)• Operational Waiver – ensure only funding ACO efforts• Patient Incentive Waiver – very narrow. Even though
would be more useful to provide more incentives to patients only have a very narrow exceptionpatients only have a very narrow exception
• Shared Savings Distributions – only applies to Medicare and not distributions from private payors
1919
![Page 20: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/20.jpg)
Lessons Learned (cont.)
3. Designers of ACO concept agree it does not work unless it is applied to both commercial and Medicare patients (i.e.,
't it til l b M di b fi i i tcan't wait until people become Medicare beneficiaries to engage them in their own care) yet combining both may in one ACO not be practical.
2020
![Page 21: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/21.jpg)
Lessons Learned (cont.)
4. Need to instill a sense of operational compliance in employees handling reporting functions.• As organizations press down on employees to improve
performance, you create the risk of misrepresenting data inputs that impact the ACO's performance, e.g., p p p , g ,employee's bonuses tied to performance might encourage misreportingN d i d d d l• Need to meet reporting standards and employees need to appropriately document standard met
2121
![Page 22: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/22.jpg)
Lessons Learned (cont.)
5. If beneficiary attribution drops below 5,000, ACO can be removed from program. Small ACO close to 5,000 has to
t h d ffi i t ti i t t t iwatch and ensure sufficient participant agreements stay in place to attribute beneficiaries.
• Beneficiaries can come in and out of ACO so make sure have well over 5,000 members
2222
![Page 23: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/23.jpg)
Lessons Learned (cont.)
6. One‐Sided and Two‐Sided Models. ACOs often start with one‐sided model with no downside risk. Required to go i t t id d i k d l ft fi t tinto two‐sided risk model after first term.
• Reinsurance is an option in two‐sided model but must be listed in the applicationpp
• Consider addressing risk assumption in ACO documents and participation agreements
2323
![Page 24: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/24.jpg)
Lessons Learned (cont.)
7. Quality factors can change throughout the program but not within a performance year.
• You may want to select or incentivize other quality measures
• Meaningful use of EHR double counted• Meaningful use of EHR double counted• ACOs with better quality scores obtain higher shared
savings payment
2424
![Page 25: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/25.jpg)
Lessons Learned (cont.)
8. Focus on IT solutions.• Connectivity issues• Platforms to analyze data• HIPPA applies – ACO are business associates of
participants rather than co ered entitiesparticipants, rather than covered entities
9 Skill set from Medicare ACO program can be transferred9. Skill set from Medicare ACO program can be transferred into commercial market ACOs and vice versa.
2525
![Page 26: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/26.jpg)
Lessons Learned (cont.)
10. Successful population health management requires care management programs and trained professionals that are integrated with care teamintegrated with care team.• 2009 study: almost 10% of Medicare beneficiaries
readmitted within 30 days of discharge and 34% re‐h i li d i hi dhospitalized within 90 days
• Embedded case managers serving as patient point of contact upon admission, discharge and transition between organizations and care settings can link patients to resources that result in improvements in clinical outcomes One pilot program had 50% fewer hospital days per
1,000 patients, 45% fewer admissions and 56% fewer readmissions after embedding case
2626
fewer readmissions after embedding case managers
![Page 27: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/27.jpg)
Lessons Learned (cont.)
11. Population Management Tools.
12. Successful Care Coordination and patient management needs access to timely, accurate and complete health informationinformation.• Health information technology ("HIT") and health
information exchanges ("HIE") make possible proactive management of the ACO's population
• Example: Informing ACO and patient care teams of patient emergency department visits and hospitalpatient emergency department visits and hospital admissions at both ACO and non‐ACO facilities
2727
![Page 28: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/28.jpg)
Lessons Learned (cont.)
12. Successful Care Coordination and patient management needs access to timely, accurate and complete health information (cont).
With t HIT h ti t t i• Without HIT when a patient presents in an emergency room outside of the ACO, an ACO may not learn of that episode of care until it receives retroactive claims data f CMS b hi h ti th ti t h i dfrom CMS by which time the patient may have incurred significant costs which are attributed to ACO and affect ACOs performance on cost and quality measures
• One study found intervention that began with hospitalization and follow the patients through discharge reduced subsequent hospitalizations within 30 days by 30%
• Another study found early post‐discharge follow up has been shown to reduce overall hospitalizations by 25%
2828
![Page 29: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/29.jpg)
Lessons Learned (cont.)
12.Successful Care Coordination and patient management needs access to timely, accurate and complete health i f ti ( t)information (cont).
• A recent study found that providers with HIE performed better on quality measures and
d b bl d dincurred savings attributable to reduced hospitalizations and duplicative lab and radiology orders
• Another study found providers achieved significant cost savings from utilizing the HIE network rather than transmitting data through fax and mail
2929
![Page 30: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/30.jpg)
Lessons Learned (cont.)
13.Patient Engagement ‐While technology is a necessary component of a patient engagement strategy, successful ti t t d lf tpatient engagement and self‐management programs
require trained professionals (from nurses, social workers and physicians) investing time and effort to help patients become engaged in meeting their health objectives.
3030
![Page 31: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/31.jpg)
Lessons Learned (cont.)
14. Integrating Data ‐ ACO providers have to develop fully integrated clinical and administrative systems to report d t b t d l d t b t i di id l iddata about and analyze data about individual providers.
• None have received patient identifiable data from CMS
• ACOs must be capable of integrating CMS patients identifiable claims data with their own clinical and administrative informationclinical and administrative information
3131
![Page 32: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/32.jpg)
APPENDIX
1. ACO Models2. Final Regulations Overview3. Governance/Leadership4. Composition of the Governing Body5. Governing Body/Conflicts of Interest6. Leadership and Management7 P i C Ph i i7. Primary Care Physicians8. Assignment of Beneficiaries9. ACO Entity/Participants10. Required Process10. Required Process11. Shared Savings12. Determining Shared Savings13. Data Sharing14. Quality Measures15. Legal Tensions16. Legal Wavier Applicable to ACOs17 T E ti f ACO
3232
17. Tax Exemption for ACO
![Page 33: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/33.jpg)
ACO Models
1. Hospital Controlled Model
2. Hospital Network Joint Venture
3 /3. Hospital/Physician Network Joint Venture
3333
![Page 34: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/34.jpg)
1. Hospital Controlled Model
HospitalHospital
ACO CMSEmployed Physician Network
$
Clinics
$$ $
Independent Physicians
Other Providers/Suppliers
3434
pp
![Page 35: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/35.jpg)
2. Hospital Network Joint Venture
HospitalDeveloper/ ManagerHospital Manager
(Private Equity)
ACO CMSEmployed Physician Network
$
$
Clinics
$$ $
Independent Physicians
Other Providers/Suppliers
3535
![Page 36: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/36.jpg)
3. Hospital/Physician Network Joint Venture
Physician H i lPhysician Network
Hospital
ACO CMSClinics $ $
$ $
Hospital Other Providers/Suppliers
3636
![Page 37: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/37.jpg)
Final Regulations Overview
Governance/Leadership Leadership and Management Assignment of Beneficiaries ACO Entity/Participants Required Processes Shared SavingsData SharingData SharingQuality Measures Legal Tensions/Waivers Legal Tensions/Waivers
3737
![Page 38: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/38.jpg)
Governance/Leadership
Governing body with authority to implement the processes to promote evidence‐based medicine, patient engagement,
t lit d t d di treport on quality and cost measures, and coordinate care.
Governing body members must have a fiduciary duty to the Governing body members must have a fiduciary duty to the ACO and act consistent with that fiduciary duty.
Governing body must have a transparent governing process.
3838
![Page 39: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/39.jpg)
Composition of the Governing Body
At least 75% control of the ACO's governing body must be held by ACO participants.
ACO must provide for meaningful participation on the governing body for ACO participants or their designatedgoverning body for ACO participants or their designated representatives.
Governing body must contain a Medicare beneficiary representative served by the ACO.
3939
![Page 40: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/40.jpg)
Governing Body/Conflicts of Interest
Governing body must have a conflict of interest policy for its members.
Governing body members required to disclose relevant financial interestsfinancial interests.
Processes to determine and address any conflicts that arise.y
4040
![Page 41: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/41.jpg)
Leadership and Management
Leadership and management structure to include clinical and administrative systems that support the Shared Savings PProgram.
Clinical management and oversight to be managed by a Clinical management and oversight to be managed by a senior‐level medical director who is a physician and ACO provider.
Medical director must be physically present on a regular basis at an office or clinic participating in the ACObasis at an office or clinic participating in the ACO.
4141
![Page 42: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/42.jpg)
Primary Care Physicians
ACO must include a sufficient number of primary care physicians for the number of fee‐for‐service beneficiaries
i d t th ACOassigned to the ACO.
ACO must have at least 5 000 assigned beneficiaries ACO must have at least 5,000 assigned beneficiaries.
4242
![Page 43: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/43.jpg)
Assignment of Beneficiaries
Step One:Determine beneficiaries who received primary care services
from an ACO primary care physician.
Beneficiar is assigned to the ACO here patient inc rred Beneficiary is assigned to the ACO where patient incurred greatest amount of allowed charges for primary care services from one or more of the ACO's primary care physicians.
4343
![Page 44: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/44.jpg)
Assignment of Beneficiaries (cont.)
Step Two:Determine beneficiaries who received primary care services
from an ACO specialist but not a primary care physician.
Beneficiar is assigned to the ACO here patient inc rred Beneficiary is assigned to the ACO where patient incurred greatest amount of allowed charges for primary care services from one or more of the ACO's specialist physicians.
4444
![Page 45: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/45.jpg)
ACO Entity/Participants
Legal entity formed under applicable state, federal or tribal law
Participants that may form an ACO• Ph sician practice• Physician practice• Networks of physician practices• Partnerships or joint venture arrangements betweenPartnerships or joint venture arrangements between
hospitals and ACO professionals• Hospitals employing ACO professionals• Certain critical access hospitals• Rural health center
d ll l f d h h
4545
• Federally qualified heath center
![Page 46: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/46.jpg)
Required Processes
An ACO must adopt and periodically update processes to:• Promote evidence‐based medicine for diagnosis with
significant potential to achieve quality improvementssignificant potential to achieve quality improvements• Evaluate health needs of the ACO's population and a plan to
address the needs• Promote patient engagement through surveys, evaluatingPromote patient engagement through surveys, evaluating
health needs, communication of processes, and standards for beneficiary access to their medical records
• Internally report on quality and cost metricsInternally report on quality and cost metrics.• Coordinate care across and among primary care, specialists
and other providers/suppliers
4646
![Page 47: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/47.jpg)
Shared Savings
Actual Part A and Part B expenditures are compared to the Benchmark
Benchmark is comprised of estimated Part A and Part B expenses with risk adjustments for changes in health statusexpenses with risk adjustments for changes in health status and demographics
3 month claims run out with a completion factor
Truncate claims exceeding 99th percentile
Required to meet minimum quality standards
4747
Required to meet minimum quality standards
![Page 48: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/48.jpg)
Shared Savings
One‐Sided Model Two‐Sided Model
Upside Saving OnlyShare up to 50% savings
b d i
Savings & LossesShare up to 60% savings
b d i
INCENTIVESHARINGRATE based on maximum
quality scorebased on maximum quality score
RATE
2.0‐3.9% depending on number of assigned b fi i i
2%MINIMUMSAVINGS
beneficiariesRATE
4848
![Page 49: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/49.jpg)
Shared Savings (cont.)
One‐Sided Model Two‐Sided Model
10% of Benchmark
/
15% of BenchmarkPAYMENTLIMITATION
n/a 2%MINIMUMLOSS RATE
n/a 5% in year 1 7 5% in year 2
LOSSSHARINGLIMIT 7.5% in year 2
10% in year 3LIMIT
4949
![Page 50: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/50.jpg)
Determining Shared Savings
Actual Medicare expenditures in the performance year is compared to the Benchmark
If applicable Minimum Savings Rate and Quality Standard achieved then eligible for Shared Savingsachieved then eligible for Shared Savings
Calculate applicable Sharing Ratepp g
Compare Amount of Shared Savings Payable to ACO to Sharing Cap
5050
![Page 51: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/51.jpg)
Data Sharing
ACO receives aggregate de‐identified reports with claims data used to create the benchmark and quarterly updates
ACO may request beneficiary‐identifiable data upon request and execution of a data use agreementand execution of a data use agreement
ACO has to notify beneficiary of request for datay y q
Beneficiary has right to decline data identification
5151
![Page 52: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/52.jpg)
Quality Measures
Year 1 – ACO assessed on complete and accurate reporting for all quality measures
Subsequent years – ACO assessed on reporting and attainment level of quality domain measuresattainment level of quality domain measures
30% minimum attainment level for each quality performance q y pbenchmark
ACO will receive points on a sliding scale when performance at or above 30% of performance benchmark
5252
![Page 53: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/53.jpg)
Quality Measures (cont.)
Performance at or above 90% of performance benchmarks earns maximum points
33 quality measures divided into four domains:1) Patient/care gi er e perience1) Patient/care giver experience2) Care Coordinator/patient safety3) Preventive health3) Preventive health4) At‐risk population
5353
![Page 54: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/54.jpg)
Quality Measures (cont.)
ACO must score above 30% on 70% of measures in each domain or subject to corrective action plan
ACO achieves 30% on at least one measure in each domain and realizes shared savings then it is eligible to receive aand realizes shared savings then it is eligible to receive a proportion of shared savings
Proportion of shared savings is calculated by points earned to points available in each domain then averaging the ratios for each domaineach domain
5454
![Page 55: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/55.jpg)
Legal Tensions
With aligning and incentivizing Physicians to manage care to reduce costs
( )( ) d d 501(c)(3) Standards • no payment for referrals, no private benefit
Anti‐Kickback Statute • no payment for referrals
Stark • no referrals where prohibited financial relationships• no referrals where prohibited financial relationships
Anti‐Trust laws • no market power
CMP • no payment to limit services in hospital setting• no payment to beneficiaries as inducement to receive
5555
p yservices
![Page 56: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/56.jpg)
Legal Waiver Applicable to ACOs
Waivers apply to:• Anti‐Kickback Statute• Stark Law• Civil Monetary Penalty Statute
Five waivers cover certain arrangements relative to ACO formation, operation, shared savings distributions and beneficiary incentivesy
Waivers protect ACO applicants, service providers, suppliers and participants
All waivers are tied to the Share Savings Program
5656
All waivers are tied to the Share Savings Program
![Page 57: ACO - Ed White - ppt.pptx [Read-Only]€¦ · clinical and administrative information 31. APPENDIX 1. ACO Models 2. Final Regulations Overview 3. Governance/Leadership 4. Composition](https://reader033.vdocuments.site/reader033/viewer/2022050304/5f6c921330b49352fb5d2544/html5/thumbnails/57.jpg)
Tax Exemption for ACOs
IRS indicated it will apply "lessening the burdens of government" standard which will allow Medicare ACOs to bt i 501( )(3) t tobtain 501(c)(3) status
IRS has a concern with private payors added to the ACO IRS has a concern with private payors added to the ACO
"Community benefit" standard should be available to allow yMedicare and private payor ACOs achieve 501(c)(3) status
5757