NAACOS In-Depth Review: ACO Proposed Rule

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The webinar will begin at 2:00 pm ET. Please make sure you are dialed in to the webinar on your telephone with the audio pin.

Agenda

1. Housekeeping

2. Presentation: • Opening remarks and initial impressions • Review of key proposals • Feedback from our audience • NAACOS next steps and advocacy

1. Audience Q&A and follow-up

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Housekeeping

1. Speaker will present for around 45 to 50 minutes

2. Q&A will take the remainder of the time • You can submit written questions using the Questions tab

(not chat) on your dashboard to the right of your screen at any time during the webinar

3. Webinar is being recorded • Slides and recording will be available on the NAACOS

website within 24 hours. You will receive an email when they are available.

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Speaker

Allison Brennan, National Association of ACOs Allison Brennan, MPP, is the vice president of policy for NAACOS where she helps develop and advocate for policies to benefit ACOs. Prior to NAACOS, Allison was a senior advocacy advisor at MGMA where she helped lead their advocacy efforts, focusing on federal regulatory and legislative issues and coordinating MGMA advocacy activities. Before joining MGMA, she worked as a program manager at the Brookings Institution. She began her career interning in the United States Senate and then worked at the National Patient Advocate Foundation. Allison has a bachelor's degree in government and economics from the College of William and Mary and holds a master's degree in public policy from Georgetown University, with a focus on health policy.

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Speaker

Jennifer Gasperini, National Association of ACOs Jennifer Gasperini joined the National Association of ACOs (NAACOS) in May of 2016 as Senior Policy Advisor where she works on federal regulatory issues facing ACOs. Jennifer brings 10 years of health policy experience on both the state and national levels. She came to NAACOS from the North Carolina Medical Society (NCMS) where she served as the Director of Health Policy, working on a variety of state and federal health policy issues concerning physicians. Before joining the NCMS, Jennifer worked at the National Medical Group Management Association (MGMA) where she focused on federal legislative and regulatory issues pertaining to physician quality and payment including ACO issues, and value-based payment programs such as PQRS and the Value Based Payment Modifier. Jennifer holds a bachelor’s degree in journalism, minor in political science from the Pennsylvania State University and a master’s degree in legislative affairs from the George Washington University.

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Overview and Initial Thoughts on MSSP NPRM

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MSSP NPRM

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• On August 9, CMS released their much anticipated MSSP Notice of Proposed Rulemaking (NPRM) o Titled Medicare Program; Medicare Shared Savings Program;

Accountable Care Organizations--Pathways to Success. o The rule can be accessed here and CMS also released a related

factsheet. o NAACOS newsletter article lists highlights of the rule; in-depth

analysis coming soon to members!

• The rule contains more sweeping program changes than anticipated, which are the most robust changes the program has seen since the first proposed rule released in November 2011

• Comments are being collected by the agency through October 16, 2018 with a final rule expected in late 2018 or early 2019

MSSP NPRM Initial Thoughts

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• This is a proposed rule and we could see significant changes in a final rule

• The proposed policies affect ACOs differently, depending on many characteristics of the ACO (ex. experience, composition, risk tolerance, etc.)

• NAACOS disagrees with CMS’s comments that ACOs do not generate savings and we are pushing back on these claims

• Opportunities exist, particularly for current ACOs and this webinar will review both opportunities as well as challenges

• Advocacy and ACO involvement will be key to shaping final policies

Opportunities

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• More gradual ramp up of risk

• Efforts to promote program stability and predictability through 5-year agreements

• More time in shared savings only model for some existing ACOs

• Makes T1+ equivalent permanent part of MSSP

• Implementation of expanded waivers and beneficiary incentives

• Allows ACOs to choose assignment annually regardless of risk

• Removes ACO measure 11 (CEHRT use) and would instead require attestation. Requests further feedback on easing quality burdens.

Opportunity for some ACOs: benchmarking changes

Challenges

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• Overall predicted decrease of ACOs

• Shortens shared savings only timeframe for all new and many existing ACOs

• Reduced shared savings rates for shared savings only/low risk ACOs

• Many sweeping program changes at once, no new Jan. 2019 cohort

• Introduces participation restrictions for ACOs based on previous TIN participation (limits opportunity to re-form and apply as new ACO)

• New early termination policies based on spending above a certain threshold (related to MSR/MLR) for 2+ years

• Requires more risk sooner from “high revenue” ACOs

• Proposed risk adjustment cap of 3% across 5 years

Proposed Program Changes

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High/Low Revenue ACOs

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• CMS proposes to differentiate between high and low revenue ACOs

• High revenue ACO means an ACO whose total Medicare Parts A and B FFS revenue of its ACO participants is at least 25% of the total Medicare Parts A and B FFS expenditures for the ACO’s assigned beneficiaries

• Low revenue ACO means an ACO whose total Medicare Parts A and B FFS revenue of its ACO participants is less than 25% of the total Medicare Parts A and B FFS expenditures for the ACO’s assigned beneficiaries

NOTES: Total ACO revenue of participants is based on revenue for the most recent calendar year for which 12 months of data are available. Total Medicare A/B FFS expenditures for the ACO’s assigned benes is based on expenditures for the most recent calendar year for which 12 months of data are available.

New Structure

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BASIC Level A

Level B

Level C

Level D

Level E

ENHANCED

25% sharing rate

25% sharing rate

30% sharing rate

40% sharing rate

50% sharing rate

75% sharing rate

Upside only Upside only 1st dollar losses at 30%, not to exceed 2% of revenue capped at 1% of BM

1st dollar losses at 30%, not to exceed 4% of revenue capped at 2% of BM

1st dollar losses at 30%, not to exceed 8% of FFS revenue capped at 4% of BM

1st dollar losses not to exceed 15% of BM

MIPS APM MIPS APM MIPS APM MIPS APM Advanced APM

Advanced APM

Options Going Forward

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ACO Start Date Options Available Risk 2012 & 2013 ACOs 1. Can choose to renew current

agreement for 1/1/19-6/30/19 • Provides additional

time in upside only

2014 & 2015 ACOs 1. Can choose to stay in current (3 year) agreement until it expires

2. Can choose to begin a new agreement 7/1/19

• Provides additional time in upside only

2016 ACOs 1. Can extend existing agreement to 7/1/19 when the ACO would enter Basic Level B or the Enhanced track

• Provides less time in upside only

2017 & 2018 ACOs 1. Can choose to stay in current (3 year) agreement until it expires

2. Can choose to begin a new agreement 7/1/19 (cannot begin at Basic Level A)

• Provides less time in upside only

2019 (new) ACOs 1. Can choose to begin an agreement period 7/1/19 or 1/1/20

• Provides less time in upside only

Options Going Forward

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1. If the legal entity or at least 40% of its TINs previously participated in another (non Track 1) ACO model, ACO is “experienced” and must participate in Basic Level E or Enhanced

2. T1 ACOs scheduled to end in 2018 may voluntarily renew for a 4th period from 1/1/19 – 6/30/19

3. For the Basic track, the previous table lists dates on which the ACO is required to start a new performance period. For most start dates, ACOs can voluntarily elect to terminate participation in June 2019 and transition higher levels of risk as of July 1, 2019

4. An ACO is re-entering if at least 50% of its participant TINs previously participated in Track 1

*Any ACO starting in 2019 will have two performance years at the same initial Level (7/1/19 – 12/31/19 & 1/1/20 – 12/31/20).

Assignment Changes

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• Proposes revisions to the definition of Primary Care Services used in assignment

• Starting Jan. 1, 2019 CMS proposes to exclude services billed under CPT codes 99304 through 99318 when such services are furnished in a SNF, using claims data to make that determination

• Changes to voluntary alignment with a proposed “beneficiary opt-in based assignment methodology”

o Would allow ACOs to elect a voluntary “opt-in” methodology with a hybrid approach discussed that would supplement an opt-in approach with a modified claims-based assignment

o An opt-in based assignment methodology would be based on an affirmative recognition of the relationship between the beneficiary and the ACO. A beneficiary would be assigned to an ACO if the beneficiary opted into assignment to the ACO or elected voluntary alignment

• CMS proposes to modify the current voluntary alignment policies to assign a beneficiary to an ACO based upon their selection of any ACO professional, regardless of specialty, as their primary clinician

Waivers

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• SNF waiver- expands use of waiver to all ACOs in downside risk models, regardless of attribution method and provides more opportunity for use of waiver by rural ACOs

• Telehealth waiver - removes originating site geographic restrictions and treats the beneficiary’s home as an originating site for all ACOs in downside risk models

• Beneficiary Incentive Program – for ACOs in downside risk models, would allow use of a CMS-approved beneficiary incentive program to provide incentive payments up to $20 to eligible beneficiaries who receive qualifying (primary care) services

Quality

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• CMS proposes to eliminate ACO measure 11, Use of CEHRT, and instead require an annual attestation that at least 50% of eligible clinicians in the ACO use CEHRT- unclear if ACOs in Basic Level A, B, C, D would still be required to report Promoting Interoperability for purposes of MIPS

• CMS also seeks feedback on ways the agency can further reduce quality reporting burdens for ACOs as part of their “Meaningful Measures” initiative

• Those who elect Basic Level E or Enhanced tracks for the 6-month performance period in 2019 would be eligible for an Advanced APM bonus and exempt from MIPS requirements (if QP thresholds are met)

• ACOs using the 6-month performance period in 2019 would still be accountable for 12 months of quality performance

Benchmark Methodology Changes

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• Maintains the overall approach to setting benchmarks but proposes modifications to how regional expenditures are factored in: o Incorporates regional expenditures into initial agreements beginning

in 2019 o Dampens the effect of moving to regional benchmarks by decreasing

the amount of the regional component of the benchmark to a 50% maximum (compared to the current 70% maximum)

o Caps the effect of the regional adjustment to +/- 5% of national per capita expenditures

o Attempts to fix problems with the regional update factor by using a national-regional blended trend rate

Risk Adjustment

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• Proposed changes would eliminate the distinction between newly and continuously assigned beneficiaries for risk adjustment

• CMS would use full CMS-HCC risk adjustment for all assigned beneficiaries between the benchmark period and the PY

• The new methodology would include a symmetrical cap of +/- 3% for the agreement period. This would apply such that the adjustment between the benchmark year 3 and any PY during the 5-year agreement period would never be more than 3% in either direction. Risk ratios would be separately capped within each of the four beneficiary enrollment types.

o Example: assuming an ACO starts in July 2019, the most the renormalized risk score used in the updated benchmark calculation can change in PY6 (2024) is between 97 to 103% of the 2018 renormalized risk score.

Notes: the full CMS-HCC risk adjustment of regional expenditures and the regional update factor would be applicable during the first agreement period due to the changes in benchmarking methodology

MACRA

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• BASIC Track Level E and ENHANCED Track would qualify as Advanced APMs under MACRA (consistent with Advanced APM status for T1+ and T3 now)

• Concerns about CMS slowing down the transition to value and undermining MACRA implementation

• CMS 2019 estimates of show a potential leveling off of QPs earning Advanced APM bonuses o 2017 projected QPs: between 70,000 and 120,000 o 2018 projected QPs: between 185,000 and 250,000 with projected

bonuses between $675 million and $900 million o 2019 projected QPs: between 180,000 and 245,000 with projected

bonuses between $600 and $800 million

Member Feedback and Moving Forward

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Member Feedback

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• As NAACOS develops positions and comments in response to this NPRM and the future of the Medicare ACO program, it is essential we hear from ACOs

• We recently met with our Board and Policy Committee to discuss this rule and have heard from many members

• We are also working collaboratively with other provider associations to respond to the rule

Polling Slide #1: Level of Support

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Considering the collective changes proposed in the MSSP NPRM, what is your ACOs overall level of support for this proposed rule?

• Strongly oppose

• Somewhat oppose

• Neutral

• Somewhat favor

• Strongly favor

Opportunities

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Please share what you consider to be the best opportunity in the rule. Using the chat feature, begin with Opportunity and share your view. Ex. “Opportunity: 5-year agreement period”

• More gradual ramp up of risk • Efforts to promote program stability and predictability through

5-year agreements • More time in shared savings only model for a number of ACOs • Makes T1+ equivalent permanent part of MSSP • Implementation of expanded waivers and beneficiary incentives • Allows ACOs to choose assignment annually regardless of risk • Removes ACO measure 11 (CEHRT use) and would instead

require attestation. Requests further feedback on easing quality burdens

• Opportunity for some ACOs: benchmarking changes

Challenges

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Please share what you consider to be the biggest challenge in the rule. Using the chat feature, begin with Challenge and share your view. Ex. “Challenge: reduced shared savings rates”

• Overall predicted decrease of ACOs • Shortens shared savings only timeframe for all new and many existing

ACOs • Reduced shared savings rates for shared savings only/low risk ACOs • Many sweeping program changes at once, no new Jan. 2019 cohort • Introduces participation restrictions for ACOs based on previous TIN

participation (limits opportunity to re-form and apply as new ACO) • New early termination policies based on spending above a certain

threshold (related to MSR/MLR) for 2+ years • Requires more risk sooner from “high revenue” ACOs • Proposed risk adjustment cap of 3% across 5 years

Polling Slide #2: Future plans

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Considering the collective changes proposed in the NPRM, how likely is your ACO to continue participating in the MSSP?

• We are extremely likely to continue participating

• We are likely to continue participating

• Neutral: we may or may not continue participating

• We are unlikely to continue participating

• We are extremely unlikely to continue participating

Tell us more about where you think your ACO is headed by using the chat feature and beginning your chat with “Future plans: …”

Moving Forward

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• Comments are due to CMS by October 16, 2018 with a final rule expected in late 2018 or early 2019

• During the comment period NAACOS will: o Continue member education and soliciting member feedback o Build coalition efforts and champions in the policy community

to support ACOs and the MSSP o Release NAACOS ACO performance data analysis to combat

claims that ACOs aren’t producing savings o Advocate to the Administration and Congress o Submit formal comments o Increase our communications efforts to share stories about the

many contributions ACOs are making

Moving Forward

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• During the comment period we need ACOs to: o Share your feedback on the rule with us! Email us at advocacy@naacos.com

o Help spread the word about ACO success by contacting local media and sharing your story (share any news coverage with us!)

o Advocate to Congress by contacting your lawmaker

o Write a comment letter to CMS in response to the rule (draft language will be provided by NAACOS)

o Help us on social media by tweeting/posting about ACO success and contributions and emphasizing the need to refine the NPRM and strengthen the Medicare ACO program through positive changes

NAACOS Fall 2018 Conference

• Save $300 by registering before August 24!

• Full agenda now available online

Agenda highlights include:

• Regulatory Update: Key Policy Provisions for ACOs in 2018 and Beyond

• CMS TownHall • Late Breaking Issues – sure

to include the NPRM • Peer-to-Peer Exchanges • Evaluating the Private Payer

Landscape

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Fall 2018 Conference October 3-5, 2018

Capital Hilton Washington, D.C.

Register Now!

Q&A

How to ask a question: • You can submit written questions using the

Questions tab (not chat) on your dashboard to the right of your screen

As a reminder, webinar has been recorded and will be available on our website within 24 hours. You will receive an email when they are available. If your questions are not answered today or if you have additional questions or comments about the proposed rule, please email us at advocacy@naacos.com.

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Final questions or comments?

Thank you!

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