member discussion on cms proposed rule...summary of key provisions of the rule increased...

Member Discussion on CMS Proposed Rule

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Objective: Distill the rule into a set of questions that we have heard from you and our staff

Thus far, 5 Critical Questions to Highlight in today’s webinar. For each question:

• Is this question relevant to you?• What information do you need to make that decision?• When do you want it?• What would you do about it?

Framework for Our Discussion


Summary of Key Provisions of the Rule

Increased Accountability Increased Flexibility Refined Methodologies

• Retiring Track 1 and 2 in

favor of a new “BASIC” track

• Shifts to downside risk (for

most organizations) after 2

years

• Limiting more experienced

ACOs to higher-risk options

• Differentiating between Low

and High Revenue ACOs -

High Revenue ACOs can stay

in upside-only programs for

a shorter time than Low

Revenue ACOs

• Beneficiary incentives: Offer patient

incentives to encourage “medically

necessary primary care services”.

• Telehealth: Telehealth services can

be furnished to prospectively

assigned beneficiaries receiving

telehealth services in non-rural

areas

• SNF 3-day waivers: Expand the

population of beneficiaries eligible

as well as the definition of SNF

affiliates eligible for SNF 3-day

waiver.

• Benchmarks: Regional adjustment

for benchmarks will be accounted

for from the beginning of the

agreement period.

• Risk Adjustment: Using full CMS-

Hierarchical Condition Category

(HCC) risk scores to adjust the

benchmark each performance year,

although restricting the upward and

downward effects of these

adjustments to positive or negative

3 percent over the new agreement

period.


• How do you plan to declare who you are responsible for:

• Step 1: What is my continuously assigned (stable) population going back to the beginning of the agreement period?

• Step 2: What is the patient population you would wish to have (e.g. Patients who have seen our most engaged physicians, conditions we are particularly good at treating)?

• Which of the following strategies will maximize the population defined above?

• Prospective Assignment with Retrospective Reconciliation• Prospective Assignment• Voluntary alignment

Question #1: What’s my Population?


Question #2: How is our ACO Defined for the Glide Path?Determine if you are a High Revenue or Low Revenue ACOWhat can you do about your designation?

Reduce your participant TINsMerge with an existing ACO

• Experience vs inexperienced: For applicants applying to enter the BASIC track for an agreement period beginning on July 1, 2019, for example, we would consider what percentage of the ACO participants participated in any of the following during 2019 (January – June), 2018, 2017, 2016, and 2015: Track 2 or Track 3 of the Shared Savings Program, the Track 1+ Model, the Pioneer ACO Model, the Next Generation ACO Model, or the performance-based risk tracks of the CEC Model.• How familiar are you with the history of your ACO participants in other programs?

• Low revenue or high revenue center: We propose to define “low revenue ACO” to mean an ACO whose total Medicare Parts A and B FFS revenue* of its ACO participants, is less than 25 percent of the total Medicare Parts A and B FFS expenditures* for the ACO’s assigned beneficiaries.• How familiar are you with the breakdown of your revenue by participants/suppliers?

• What’s the first step on this risk journey? If our ACO has to take risk, what are our options:• What are financial implications for our ACO on BASIC vs ENHANCED risk models?


Low Revenue ACOs are Allowed to Stay in BASIC Level E Longer

Low Revenue ACO Participation Options High Revenue ACO Participation Options

Applicant Type Experience with performance-based risk Medicare ACO initiatives

Basic Track’s Glide Path

Basic Track’s Level E

Enhanced Track

New Legal Entity

Inexperienced Yes - levels A through E

Yes Yes

Experienced No Yes Yes

Re-entering ACO

Inexperienced Yes –levels B through E

Yes Yes


Renewing ACO Inexperienced Yes – levels B through E

Yes Yes


Applicant Type Experience with performance-based risk Medicare ACO initiatives

Basic Track’s Glide Path

Basic Track’s Level E

Enhanced Track

New Legal Entity

Inexperienced Yes - levels A through E

Yes Yes

Experienced No No Yes

Re-entering ACO

Inexperienced Yes – levels B through E

Yes Yes


Renewing ACO Inexperienced Yes – levels B through E

Yes Yes


Source: Proposed Rule (page 173)

Low revenue ACOs may operate under the BASIC track for a maximum of two agreement periods.

High revenue ACOs that have participated in the BASIC track are considered experienced with performance-based risk Medicare ACO initiatives and are limited to participating under the ENHANCED track for subsequent agreement periods.


Steep Cliff between BASIC (Track E) and ENHANCED

4%

15%

0%

20%BASIC

ENHANCED

Cap on Shared Losses in ENHANCED Track greatly exceeds that of BASIC

BASIC LEVEL E (risk/reward)

ENHANCED Track(Current Track 3)

Shared Savings (once MSR met or exceeded)

1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark

No change. 1st dollar savings at a rate of up to

75% based on quality performance, not to

exceed 20% of updated benchmark

Shared Losses (once MLR met or exceeded)

1st dollar losses at a rate of 30%, not to exceed the percentage of revenue

specified in the revenue-based nominal amount

standard under the Quality Payment Program (for example, 8% of ACO

participant revenue in 2019 –2020), capped at a percentage of updated benchmark that is

1 percentage point higher than the expenditure-based

nominal amount standard (for example, 4% of updated

benchmark

No change. 1st dollar losses at a rate of 1 minus

final sharing rate, with minimum shared loss rate of 40% and maximum of 75%, not to exceed 15% of

updated benchmark

% o

f Ben

chm

ark


• Merge our ACO with a later start:• If I merge a 2016 ACO into a 2018 ACO – Do I get some additional running room in BASIC

Track E?• Do I have the option of merging with other ACOs; those starting in 2017 or 2018

• Keep my ACO, reformulate my participant roster• How are my participants contributing to my revenue totals?• What is the cost/benefit of keeping these participants in the ACO?

Question #3: What Choices do we have to Redefine Our ACO?


Institutional Providers Owning

or Operating ACO Participants

Rule References Track 1+ Methodology When Describing High/Low Revenue

ACO Participants

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP_Application_ACO_Track1+_Model.pdf

Organizations that own or operate one

of the following

institutional providers

Reading the rule, the spirit of the rule implies and references Track 1+ definitions, but at initial review, it appears more narrowly tied to ACO Participant roster.


Proposed Rule Expands Availability of Waivers for Eligible ACOs

Beneficiary incentives: Allow eligible ACOs the ability to offer patient incentives to encourage “medically necessary primary care services”.

Telehealth: • Allow for payment for telehealth services furnished to prospectively assigned beneficiaries receiving telehealth

services in non-rural areas • Allow beneficiaries to receive certain telehealth services at their home, to support care coordination across

settings.

SNF 3-day waivers: • Allow eligible ACOs under performance-based risk under either prospective assignment or preliminary

prospective assignment with retrospective reconciliation to use the program’s existing SNF 3-day rule waiver. • Amend the existing SNF 3-day rule waiver to allow critical access hospitals (CAHs) and other small, rural

hospitals operating under a swing bed agreement to be eligible to partner with eligible ACOs as SNF affiliates for purposes of the SNF 3-day rule waiver.


CMS is offering up enabling ingredients that would allow you to improve care for patients. We are not just curious about how you intend to invoke these waivers, but how will you use these to improve your care models?

• Might the telehealth waiver help me meet TCM requirements?

• Are there standardized assessments to determine whether a patient is eligible a good candidate for the 3-day SNF waiver?• How do you operationalize the SNF 3-day waiver?

• How can the beneficiary incentives allow me to begin conversations around care models such as Shared Decision Making with eligible beneficiaries?

Question #4: How Can We Leverage These Waivers to Better Serve Patients?


Can we Reduce the administrative burden of informing ACO Beneficiaries at the “First Point of Contact” How does the Rule Advance the MyHealthyData Initiative?

“Therefore,wewillprioritizethedevelopmentofprocedurestoimplementvoluntaryalignmentusinganautomatedprocesswith theintentofincorporatingbeneficiaryattestationsintotheclaims-basedassignmentalgorithmbeginningwiththe2018performanceyear.

WedonotintendtodevelopamanualbeneficiaryattestationprocessundertheSharedSavingsProgram.”

member discussion on cms proposed rule...summary of key provisions of the rule increased...

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