aco final rule highlights
TRANSCRIPT
ACO Final Rule: HighlightsAdele Allison,National Director of Government Affairs, SuccessEHS
What is the ACO Final Rule?
Substantial changes were made to the proposed rules for participating in ACOs. The Final Rule was released on Oct. 20, 2011.
What is an Accountable Care Organization (ACO)?“Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.”
ACOs Contract with CMS
-Three-year contract term – applies to all stakeholders & participants
-Must have sufficient Primary Care Providers and minimum of 5,000 Medicare Physician Fee Schedule beneficiaries
-ACO must be a legal entity with a single TIN (taxpayer identification number)
-Must have shared-governance with 75% of ACO participants
-Payment made to ACO TIN – no authority of distribution downstream
-PCPs are limited to participation with ONE ACO (Not intended to be punitive; Exclusivity based upon the PCP’s TIN)
-Retain records for 10 years (active ACOs) or 6 years (from date of termination)
FQHCs & Rural Health Centers
−Notice of Proposed Rulemaking (NPRM) → FQHCs and RHCs are ineligible to form ACOs
−UPDATED Final Rule §425.102 – FQHCs and RHCs may form an ACO
−Limitation initially due to assignment based on Primary Care Provider (PCP) and claims data
−CMS cross-walked relevant PCP CPTs to Revenue Codes
−CMS removed requirement of PECOS number for participation
−FQHCs and RHCs forming ACOs must provide list of PCPs and NPIs who render care at their facilities
ACOs & Hospitals
−CMS has established no “hospital-oriented” requirements−ACO does NOT have to
have a participating hospital
−HOWEVER…−CAHs billing under Method II
may form independent ACO
−HOWEVER…−Hospitals employing ACO
professionals−Can feasibly be the only ACO
member of the governing body through employment relationships−Meet the 75% ACO participant
shared-governance requirement
−Encourages market consolidation−Antitrust concerns
Required Processes & Patient-Centered Criteria
−ACO Application Required Documentation plans to:− Promote Evidence-Based
Medicine− Promote Beneficiary Engagement− Report Internally on Quality and
Cost Metrics− Coordinate Care
−Must adopt Patient-Centered focus
−Must promote Patient-Centered care through governance and practice integration
−Strongest evidence will be PCPS that are PCMH recognized
ACO Application & Kick-Off
−CMS Applications open Jan. 1, 2012
−ACO must file NOI − www.cms.gov/sharedsavingsprogram
−Two Application periods:−ACOs starting April 1, 2012−ACOs starting July 1, 2012
−April 1, 2012 Kick-Off:−First performance year = 21 months
ending Dec. 31, 2013−Subsequent performance periods =
Calendar Year−Agreement term = 3 years ending
Dec. 31, 2015
−July 1, 2012 Kick-Off:−First performance year = 18 months
ending Dec. 31, 2013−Subsequent performance periods =
Calendar Year−Agreement term = 3 years ending
Dec. 31, 2015
Quality & Reporting – Performance
−Purpose: To ensure that Quality is not sacrificed in the name of Cost
−33 ACO Quality Performance Standards−7 related to Patient/Caregiver
experience−3 related to Care Coordination &
Patient Safety
−33 ACO Quality Performance Standards−1 calculated from EHR Incentive
Program Data−22 related to At-Risk Populations
covering:−Care Coordination−Patient Safety−Preventive Health
−33 ACO Quality Performance Standards−22 related to At-Risk Populations
covering:−At-Risk Populations for Diabetes,
Hypertension, IVD, Heart Failure & CAD
Patient / Caregiver Experience
MeasureMethod of Data
SubmissionGetting Timely Care, Appointments and Information
Survey
How Well Your Doctors Communicate Survey
Patients’ Rating of Doctor Survey
Access to Specialists Survey
Health Promotion and Education Survey
Shared Decision-Making Survey
Health Promotion and Education Survey
Care Coordination / Patient Safety
MeasureMethod of Data
SubmissionRisk-Standardized, All Condition Readmission
Claims
Ambulatory Sensitive Conditions Admissions: COPD
Claims
Ambulatory Sensitive Conditions Admissions: CHF
Claims
% PCPs that Qualify for EHR Incentive Program Payment
EHR Incentive Program Reporting
Medication Reconciliation: After Discharge from IP
GPRO Web-Interface
Falls: Screening for Fall Risk GPRO Web-Interface
Preventive Health Measures
MeasureMethod of Data
SubmissionInfluenza Immunization - MU Menu CQM and 2012 EHR-based PQRS
GPRO Web-Interface
Pneumococcal Vaccination - MU Menu CQM GPRO Web-Interface
Adult Weight Screening and Follow-up – MU Core CQM
GPRO Web-Interface
Tobacco Use Assessment and Cessation Intervention - MU Core CQM and 2012 EHR-based PQRS
GPRO Web-Interface
Depression Screening GPRO Web-Interface
Colorectal Cancer Screening - MU Menu CQM GPRO Web-Interface
Mammography Screening - MU Menu CQM GPRO Web-Interface
Adults 18+ who had BP Measured in previous 2 years
GPRO Web-Interface
At-Risk Populations
Measure Method of Data Submission
Diabetes Composite (All / Nothing Scoring): A1c Control (< 8) GPRO Web-Interface
Diabetes Composite (All / Nothing Scoring): LDL (<100) GPRO Web-Interface
Diabetes Composite (All / Nothing Scoring): BP (<140/90) GPRO Web-Interface
Diabetes Composite (All / Nothing Scoring): Tobacco Non-Use GPRO Web-Interface
Diabetes Composite (All / Nothing Scoring): Aspirin Use GPRO Web-Interface
Diabetes Mellitus: A1c Poor Control (>9) - MU Menu CQM and 2012 EHR-based PQRS
GPRO Web-Interface
Hypertension: BP Control - MU Menu CQM and 2012 PQRS GPRO Web-Interface
IVD: Complete Lipid Profile and LDL Control (<100) - MU Menu CQM and 2012 EHR-based PQRS
GPRO Web-Interface
IVD: Use of Aspirin or other Antithrombotic - MU Menu CQM and 2012 EHR-based PQRS
GPRO Web-Interface
Heart Failure: Beta-Blocker Therapy for LVSD - MU Menu CQM GPRO Web-Interface
CAD Composite (All / Nothing Scoring): Drug Therapy for lowering LDL-Cholesterol - MU Menu CQM
GPRO Web-Interface
CAD Composite (All / Nothing Scoring): ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD
GPRO Web-Interface
Quality & Other Reporting
−Quality Performance Score to include EHR ACO Adoption – Weighted twice as much as other measures
−Phasing in Pay-for-Performance over 3-year contract term
Year 1 Year 2 Year 3
# of Measures # of Measures # of Measures
Pay-for-Performance 0 25 32
Pay-for-Reporting 33 8 1
Total Measures 33 33 33
−Shared-Savings = Must score above 70% on measures
−Starting in 2014: CMS Certified Vendor required to administer and report patient experience
−Patient Experience + Claims-Based Measures will be reported publicly on “Physician Compare”
−Physician Compare site currently live−www.medicare.gov/find-a-doctor/provider-search.aspx
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