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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