impact of acos on rural healthcare...

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Nebraska HIMSS 2019 Spring Meeting

Impact of ACOs on Rural Healthcare FacilitiesTodd Searls, Regional Vice President

Caravan Health

NEBRASKA HIMSS 2019 SPRING MEETING

Disclosure(s):

Todd Searls– I have no actual or potential conflict of interest in relation to this program/presentation.

NEBRASKA HIMSS SPRING MEETING 2019 2

Agenda

- Medicare Challenges Are Rural Health Challenges / Opportunities

- Review of Medicare Shared Savings Program ACO (MSSP ACO)

- Impacts of an ACO On:◦ People◦ Process◦ Technology

- Closing

NEBRASKA HIMSS 2019 SPRING MEETING 3

Medicare Challenges Are Rural ChallengesMSSP OPPORTUNITIES ARE OPPORTUNITIES FOR CAHS/RHCS

4NEBRASKA HIMSS 2019 SPRING MEETING


Projected Federal Spending on Medicare and Medicaid

Source: Kaiser Family Foundation, Congressional Budget Office

INDUSTRY AND MARKET TRENDS

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Chronic Conditions Drive Cost


NEHIMSS 2019 7

Physician Fee Schedule Increases Will Not Keep Pace With Inflation

Risk RequiredTo Capture

0.75% Raise

$270,000

$280,000

$290,000

$300,000

$310,000

$320,000

$330,000

$340,000

$350,000

$360,000

$370,000

2 0 1 8 2 0 2 0 2 0 2 2 2 0 2 4 2 0 2 6 2 0 2 8 2 0 3 0 2 0 3 2 2 0 3 4 2 0 3 6

MEDICARE PAYMENT PER PCP/SPECIALIST TRIAD RISK VS. NO RISK

No Risk IDN Medicare Payments Risk IDN Medicare Payments

Medicare payments include fee schedule reimbursement, MIPS adjustments and shared savings.

Fee Schedule Updates

0.5%

0.5%

0.5%

0.5% 0 0 0 0 0 0

0.75%

0.25%

2015 and earlier 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 and later

QAPM

Non-QAPM

As A Result –More Physicians Joining ACOs


https://www.medscape.com/slideshow/compensation-2017-overview-6008547#1

Heightened Challenges in Rural Settings

- Increased / Inappropriate ED Usage

- Limited Access to Behavioral Health Providers

- Geography

- Limited Capital / SME Resources

- Rural Social Determinants of Health vs Urban

- Controlling ‘out of network’ costs (ie, downstream facility spend)

- Lack of Specialists

- RHC Billing setup

- Lack of Post-Acute Care Facility & CAH/RHC Communication & Care Planning



Benefits of Rural Participation in ACOs•All healthcare is local

• Rural healthcare is primary care – the very thing that Medicare wants to encourage through ACO participation

•Partnering / collaborating with a large number of peer facilities• Better access to Subject Matter Experts (SMEs)• Reduced costs of shared analytics platforms• Executive, Physician, and Population Health RN cohort building / learning networks• Improved ACO performance: more facilities = more covered lives = better ACO scoring

•Improving / increasing preventative care services• Adds financial stability• Increases patient engagement & satisfaction scores• Improves Quality Reporting / MIPS participation

•Better care coordination with specialists and post-acute settings of care


“The ACO has just been a catalyst for care coordination. Before the ACO model, we knew that we had partners that existed, but we didn’t call on one another.”

“You don’t have to be in an ACO to offer these programs, but one benefit of being in an ACO is the resources, structure, and support to effectively implement programs that positively impact patients and care.”

- MAY 30, 2018, Relationships and Partnerships: How ACOs Are Improving Treatments for Super-Utilizers, by Allee Mead https://www.ruralhealthinfo.org/rural-monitor/acos-and-super-utilizers/

https://www.ruralhealthinfo.org/rural-monitor/author/allee-mead/

ACOs – Coming To A CAH Near You!

Secretary of Health and Human Services Alex Azar talks tough to hospitals:

“…make no mistake: we will use these tools to drive real change in our system. Simply put, I don’t intend to spend the next several years tinkering with how to build the very best joint-replacement bundle — we want to look at bold measures that will fundamentally reorient how Medicare and Medicaid pay for care ….

….As just one example, we are looking at our efforts regarding Accountable Care Organizations. The program was intended to give providers three years to learn how to accept risk and share savings, but the results have been lackluster.….

….as costs continue to skyrocket, the current system simply cannot last.


https://rupri.public-health.uiowa.edu/publications/policybriefs/2018/ACO%20Spread%202018.pdf

As of January 2018:1,210 RHCs & 421 CAHs participate in MSSP ACOs

Review of the Medicare Shared Savings ProgramOUR FOCUS TODAY IS THE MSSP ACO


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Forming an ACO

ACOs enjoy waivers of Stark, Anti-Kickback Statute and Patient Inducement regulations. They are deemed to be Clinically Integrated Networks by the FTC.

• ACO professionals in grouppractice arrangements

• Networks of individual practices of ACO professionals

• Partnerships or joint venture arrangements between hospitals and ACO professionals

• Hospitals employing ACO professionals

• Federally qualified health centers

• Rural health clinics

Must serve at least 5,000 Medicare fee-for-service patients.

Agree to participate for at least 5 years, meet other program requirements such as a governing body, processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost measures and coordinate care.

Eligible Participants



Most ACOs Cannot See True SavingsSmall ACOs experience savings and losses +/- 10-20% simply due to statistical variation in health care spend and in HCC coding

73% of MSSP ACOs have fewer than 20,000 lives

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,0002013 2014 2015 2016


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/SSP-2018-Fast-Facts.pdf

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2020 – Pathways MSSP Model

Level A Level B Level C Level D Level E ENHANCED

Risk Upside only Two-sided Two-sided Two-sided Two-sided

Shared Savings 1st dollar savings, rate of 25%

1st dollar savings, rate of 30%




Shared Losses NA

1st dollar losses, rate of 30%, not to exceed 2% of revenue or 1% benchmark

1st dollar losses, rate of 30%, not to exceed 4% of revenue or 2% benchmark

1st dollar losses, rate of 30%, not to exceed nominal risk standard (currently 8% of revenue or 4% of benchmark)

1st dollar losses, rate of 1 minus sharing rate (40-75%), not to exceed 15% of benchmark

QPP Status MIPS APM Advanced APM

Advanced APM

Predecessor Track 1 NA NA Track 1+ Track 3

BASIC


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Why Take Risk?ACO participants taking risk will get 5% lump sum payments that are not counted in shared savings and are exempt from MIPS reporting – making your clinicians happier and more attractive to others in value-based payments.

CMS is steadily increasing incentives for risk-takers Higher rewards for MSSP performance

Reduce risk corridor to 0.5% or lower

Direct admissions to SNFs

Telehealth to patients homes as a billable visit

Exempt from MIPS and Meaningful Use

0.5% higher annual increases in Part B starting in 2026 that will accumulate over time to the clinicians NPI.

It will be difficult to recruit physicians if you do not take risk. Beginning in 2026, every year a clinician does not take risk his lifetime earning potential decreases by 0.5%.


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Should We Worry About Being Pushed into Risk Too Early?

There is no reason to panic

We have seen that the longer ACOs stay in the program, the stronger the results

CMS is proposing to continue low or no downside risk for the early ACO years

Large Collaborative ACOs are in a great position to take on risk in future years

If your ACO has a strong population health focus, routinely performs PDSA improvement activities, and has robust data analytics, you are well positioned for Risk


PeopleRIGHT PERSON / RIGHT SEAT



The ACO Core Team Clinical & Ancillary

- Physician Champion

- Population Health RN

- RN Champion

- Pharmacy Lead

- ACO Champion

Administrative / HIM / IT

- Executive Sponsor(s) (CEO / CFO / COO)

- ACO Champion

- IT Lead

- Coding Lead

- Analytics Super User

- Compliance Lead

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Solidify Provider Relationships

Ensure your physician contracts

encourage a collaborative work

environment

Establish a level of trust between

providers to leverage each other’s

strengths

Keep an open line of communication so PCPs, specialists and facilities can

most effectively work together


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Empower Your Nurses

Build your primary care capacity.Utilize nurses and medical assistants to meet patient needs and provide additional support to providers.

Medicare allows important preventive services to be billed under provider supervision.

Physicians get more time to attend acute patient needs, and patients benefit from more attention overall.


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Trained Nurses Excel at PreventionNo AWV

(n=15,232)AWV done by MD/NP

(n=446)AWV done by QMnurse (n=2,863)

Men up to date on AAA screen 70.1% 77.7% 83.8%

Women up to date on mammogram 42.2% 61.1% 74.0%

Women up to date on bone density 45.3% 63.5% 75.1%

Up to date on PCV-23 vaccine 33.4% 57.6% 58.4%

Up to date on depression screening 1.9% 3.4% 94.9%

Up to date on Health Risk Assessment 1.9% 2.0% 94.3%

Up to date on Fall Risk Screening 1.9% 2.0% 94.3%

Up to date on ADL Assessment 1.9% 2.0% 94.3%

Up to date on Smoking Cessation screen 1.9% 2.0% 94.3%

Up to date on End of Life Plan screen 1.9% 2.0% 93.8%

Source: Hattiesburg Clinic



Population Health Nurses Generate IncomeFFS Sites RHC Sites

Population Health Nurse

Wellness Visits

($118/yr)

Chronic Care Management ($45-$90/mo)

Advance Care

Planning ($86/yr)

Behavioral Health

Integration ($126 /mo)

Cognitive Assessment & Planning

($238/yr)Population

Health Nurse

Wellness Visits (AIR)

Chronic Care Management

(~$67/mo2019 Rate)

Advance Care

Planning (AIR if

Standalone)

Behavioral Health

Integration ($67/mo)

Cognitive Assessment & Planning

($238/yr)

Don’t forget billing for the IPPE (PA / APRN), Home Health Supervision, & Other Screenings!

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Total: 5512 4900 $821,117.55

CY 2018 CY 2017

ACO Sites: CY2017 CY2018 39% Services $784,138.25

ACO Clinics

Case Study: Caravan HealthMSSP ACO ~17,000 Attributed Lives

(Predominantly CAH/RHCs)


CY 2018 CY 2017

ProcessPLAN, DO, STUDY, ACT


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Have a Plan to ExecuteFocus on Execution

Don’t just have a plan –focus on the end result

Identify New Resources

Dedicate new resources and technologies to project planning, management and tracking above and beyond clinical staff and technology investments.

Adapt to New Processes

Even if you are a high-performing health system, there is always room for improvement.


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Meet Practices Where They Are


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Build on Performance

Expertise & Compliance

Practice Transformation

Clinical Excellence

Intelligence & Analytics

Guidance through the complex regulatory environment and governance procedures

Drive clinical and non-clinical transformation initiatives

Lead the physician engagement aspects of value-based care

Healthcare data experts delivering mission-critical insights

Implement

Report

Teach

Improve


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Get Your Coding in OrderEnsure you receive credit for the sicker patients you treat

• Appropriate HCC coding is required for value-based payments.

• Numerous ACOs have found that inattention to HCC-coding workflows has been the difference between collecting shared savings and falling below the minimum savings rate.

• Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy.


Documentation & Coding Affect ReimbursementAll conditions coded appropriately Some conditions coded – poor specificity No conditions coded

76 year old female 0.468 76 year old female 0.468 76 year old female 0.468

Medicaid eligible 0.177 Medicaid eligible 0.177 Medicaid eligible 0.177

Diabetes w/ vascular complications

0.608 Diabetes w/o vascular complications

0.181 Diabetes w/o vascular complications

Vascular disease w/ complications

0.645 Vascular disease w/o complications

0.324 Vascular disease w/o complications

CHF 0.395 CHF CHF

Disease Interaction(DM + CHF)

0.204 Disease Interaction(DM + CHF)

Disease Interaction(DM + CHF)

Total RAF 2.497 Total RAF 1.15 Total RAF 0.645

PMPM Payment $1,873 PMPM Payment $863 PMPM Payment $484

Annual Payment $22,473 Annual Payment $10,350 Annual Payment $5,805


Technology2015 CEHR IS JUST THE STARTING POINT



Does Your EHR Make ACO Workflows Easier?

- HCC Module?

- AWV Templates?

- CCM Time Capture?- Patient Self-Scheduling?

- Patient Self-Reported Health Information?◦ Blood Pressure◦ Blood Sugars◦ Assessment Forms

Attribution Maps


• ACO Analytics Platforms Should Be Able To Track Your Attributed & Assignable Lives.• Attribution drives shared savings!

• Do you know where your patients live?• What community support services are

available to assist patients in keeping to their care plan?

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Why Is Attribution Important?Total Opportunity

Shared Savings Earned (PBPY)

# of Medicare Beneficiaries (Attribution)

• 30% of ACO shared savings are distributed on pure attribution• 60% based on attribution and local PBPY savings• 10% goes to the top quality performers


Analytics: Internal & External Data



Be Sure To Keep ScorePractice ABC

Category Metric PointsPoints

PossibleRN Care Coordinator in place ✓ 6 6Physician Leader in place ✓ 6 6Lightbeam Interface Status as of X/X/XXXX date In Dev. 4 6# Active Medicare AWV Cases - Claims + EHR Interface Data Q1 2017 300 0% of patients with AWV - full credit for over 50% 41.0% 4 6# Active Medicare CCM Cases - Self Reported Q1 2017 140 0% of patients in CCM - full credit for over 10% 17.0% 6 6# Active Medicare TCM Cases - Self Reported Q1 2017 170 0% of patients in TCM - full credit for over 10% 8.0% 4 6Billing AWV ✓ 4 4Billing CCM ✓ 4 4Billing TCM ✓ 4 4Billing Advance Care Planning (ACP) X 0 4Patient Satisfaction Tablet Utilization Rate 27.0% 6 6Quality score 100.0% 6 6Total Cost - full credit for reduction beyond statistical threshold -3.2% 6 6ED utilization - full credit for reduction beyond statistical threshold -2.5% 2 2SNF utilization - full credit for reduction beyond statistical threshold 3.0% 0 2IP utilization - full credit for reduction beyond statistical threshold -1.0% 2 2Representative at Board Meeting ✓ 4 4ACO Champion at Road Map Call ✓ 2 2Practice Manager at Road Map Call ✓ 2 2Care Coordinator at Road Map Call ✓ 2 2Attend QIW ✓ 4 4Attend Care Coordinator Cohort Calls ✓ 4 4Attend Quarterly Steering Committee Meeting ✓ 3 3Attend Cohort Calls ✓ 3 3

TOTAL SCORE 88 100

ACO BOARD SCORECARD ADDITIONS/ADJUSTMENTSAttend EBM Webinars X 0 2Attend Cohort Calls ✓ 2 2Attend Physician Leader Cohort Calls ✓ 2 2

Status

Physician Lead

ACO Medical Director

Key Billing Indicators

Care Coordination

Outcomes

Leading Indicators

Staff Engagement

Use a scorecard to keep focused on goals and pinpoint areas of weakness.

Metrics should be based on efforts towards goals such as AWV percentage rate or cohort meeting participation.

Please Note: RHCs / CAHs and the ACOAS EXPECTED – SIMILAR, BUT DIFFERENT


Why Does RHC/FQHC Status Matter?• RHC/FQHC billing differs substantially from fee-for-service (FFS)

o Unique billing codes are required to allow your facility to receive reimbursement for important care management services

• Claims billed under the All-Inclusive Rate (AIR) do not contain the same information as FFSo Alternative methodology is used to determine ACO patient attribution

• Certain FFS policies have become intertwined with the Shared Savings Programo You may be required to participate in additional programs to support your

FFS ACO partners


Shared Responsibility in the ACO•When participating in a Shared Savings ACO, your TIN(s) will be scored with the APM entity (the ACO);

•Because of participation in the ACO, RHC/FQHC participants are not exempt by virtue of the low volume threshold;

•All members of the ACO will receive an identical MIPS score (for their ACO TIN(s));•Failure of an RHC/FQHC to participate in MIPS will negatively impact all of their fee-for-service ACO partners.


CAHs – Something to Consider… Advanced Alternative Payment Models (Advanced APMs)Advanced APMs are APMs that meet these 3 criteria:1. 3/4 majority use of certified EHR technology;2. Provides payment for covered professional services based on quality measures comparable to

those used in the MIPS quality performance category; and3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2)

requires participants to bear a significant financial risk (ie, Track E & Enhanced Track under Pathways to Success MSSP model).

Advanced APM Potential Benefits (for Qualified Participants (QP)):1. 5 percent bonus on all Medicare Part B Charges (Method II Billing anyone? But follows provider…)2. APM-specific incentives (ie, shared savings payment if achieved)3. Exclusion from MIPS (all QP providers within ACO)4. Waivers, waivers, waivers! (3 Day rule, beneficiary incentive, telehealth to home, etc.)


QP Status: It’s All About That Billing, ‘bout That Billing…QP Status Determination:

Using the 2018 MSSP Track 2 & Track 3 example:

- A provider would be considered a QP if their total Medicare Part B charges (attributed lives / attribution-eligible lives) were equal to or greater than 25%.

Question:

- Does this help or hurt your CAH Method II and RHCs?


https://qpp-cm-imp-content.s3.amazonaws.com/uploads/811/QP-Methodology-Fact-Sheet.pdf

In Summary


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Maximize Power of Claims and EHR Data

Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs.

Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.

Plan early for in-house and outsourced expertise.Ingesting claims data and drawing meaningful reports takes time.

1

2


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The Collaborative ACO Model

Master core competencies for provider-based risk• Value-based Purchasing• MACRA• Medicare ACO risk• Medicare Advantage• Medicaid Managed Care• Employer plans

5k, 10k, 25k lives are just not enough to succeed in an ACO, especially when considering Risk. Large-scale collaboration is key to MSSP Success!

Collaborative ACO Models are a great option for smaller facilities – especially when Partnering with other facilities within a region (similar patients, similar challenges)

• The Mississippi Hospital Association created the first State-wide ACO


In SummaryValue-based Payment is Here to Stay More than a third of all providers will participate in these programs. Reducing healthcare cost growth is critical for our future. Get maximum upward adjustments of Part B payments and shared savings to supplement frozen fee for service revenue.

Now is the Time to Take ActionEarly adopters reaped the benefit of risk-free participation. The move to risk is accelerating and it is important to gain experience and prepare for the future reimbursement system.

Statistical Variation will Hurt your ACOThe effects of statistical variation create unreliable and spurious results that can wrongly penalize or reward providers.

Strengthen Provider Reputation MIPS scores will be much higher for APM participants. CMS will post this data on Physician Compare in 2018 and publish for third-party use.

Maximize Value-based Reimbursement Joining a 100,000+ life ACO increases the likelihood of predictable shared savings, higher MIPS adjustments, reduces risk and sets the stage for future success in value-based payments, clinical integration and provider-based health plans.



Todd Searls, RVP | [email protected] | 816.945.6341

mailto:[email protected]

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Helping Providers Navigate the Challenges of Value-Based Payments

CPC+MACRA

Founded in 2013

38 Accountable Care Organizations

>14,000 Providers

>1,000,000 Patient Lives

Results (cms.data.gov)

95%- 97% Quality Scores

>10x National Average of Savings

ACOs Practice Transformation

About Caravan Health


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