HEALTHCARE REFORM. September 2012

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Patience Singleton
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1 HEALTHCARE REFORM Accountable Care Organizations: ACOs 101 September 2012 The enclosed slides are intended to provide you with a general overview of accountable care organizations (ACOs), created within the healthcare reform Medicare Shared Savings Program (MSSP). This tool is designed to help distributors and manufacturers understand the basics of ACOs. For example, healthcare providers will be able to share in any savings they achieve if they meet certain quality performance measures. Realigning payment incentives, such as these, may shift the way providers deliver care and make purchasing decisions. This is one of many healthcare reform resources HIDA has developed. For more information on healthcare reform, visit or contact HIDA Government Affairs at

The Basics Accountable Care Organization (ACO) A group of healthcare providers that agrees to work together to: Coordinate patient care Meet quality measurements Share in any achieved Medicare cost

4 million Medicare beneficiaries 1 Initiatives include the MSSP (with 20 ACOs entering an Advanced Payment model), Pioneer ACOs, and a Physician Group Practice transitional demonstration At-a-Glance

2 The Basics Accountable Care Organization (ACO) A group of healthcare providers that agrees to work together to: Coordinate patient care Meet quality measurements Share in any achieved Medicare cost savings, by reducing the cost to deliver care through new efficiencies There are 153 ACOs participating in Medicare shared saving initiatives, serving over 2.4 million Medicare beneficiaries 1 Initiatives include the MSSP (with 20 ACOs entering an Advanced Payment model), Pioneer ACOs, and a Physician Group Practice transitional demonstration At-a-Glance The Medicare Shared Savings Program (MSSP) is a provision of healthcare reform, which allows for the voluntary creation of ACOs by healthcare providers MSSP begins January 1, 2012; ACO agreements will begin April 1 and July 1 Providers must commit to a three-year participation agreement SKILLED NURSING FACILITY HOSPITAL PATIENT SURGI-CENTER Quality measures no longer include that providers must be meaningful users of EHR. HOME CARE 1 CMS has also announced that new ACO applications will be accepted annually for the MSSP.

3 The Goal: Coordinate Patient Care All Medicare providers may participate in an ACO, however ACO sponsors (or conveners) are limited to: Physicians in group practice arrangements Networks of individual practitioners Hospitals that are partnering with or employ eligible physicians Nurse practitioners Physician assistants Specialists Federally qualified health centers (FQHCs) Rural health clinics Critical access hospitals Low-volume hospitals Other providers, such as skilled nursing facilities, are eligible to participate, but do not have authority to convene ACOs at this time.

The Goal: Coordinate Patient Care Each ACO is prospectively assigned a minimum of 5,000 Medicare beneficiaries Medicare beneficiaries must be informed that their provider is participating in an ACO

4 The Goal: Coordinate Patient Care Each ACO is prospectively assigned a minimum of 5,000 Medicare beneficiaries Medicare beneficiaries must be informed that their provider is participating in an ACO Medicare beneficiaries have the right to decline to be part of an ACO Patients are expected to benefit from being at the center of care through Proactive case management Appropriately managed resources Improved care transitions Utilization of data on process and outcomes Coordinating Care + Measuring Quality = Improved Care

5 The Challenge: Efficient Care Quality improvement pays The amount of savings an ACO may receive is linked to their performance on 33 quality measures (see Appendix) The quality measures are organized into four domains, each with a common focus: Patient experience Care coordination and patient safety Preventive health Caring for at-risk populations Show me the money The Centers for Medicare and Medicaid Services (CMS) will develop a spending benchmark for each ACO, every year, to gauge financial performance In the first year, providers must fully and accurately report on all four quality measure domains In the second and third years, the share of savings will be tied to performance on quality measures

6 Appendix: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings Domain AIM: Better Care for Individuals 1. Patient/Caregiver Experience Measure Title CAHPS: Getting Timely Care, Appointments, and Information NQF Measure #/Measure Steward Method of Data Submission Pay for Performance Phase In R = Reporting P=Performance Year 1 Year 2 Year 2 NQF #5 AHRQ Survey R P P 2. Patient/Caregiver Experience CAHPS: How Well Your Doctors Communicate NQF #5 AHRQ Survey R P P 3. Patient/Caregiver Experience CAHPS: Patients' Rating of Doctor NQF #5 AHRQ Survey R P P 4. Patient/Caregiver Experience CAHPS: Access to Specialists NQF #5 AHRQ Survey R P P 5. Patient/Caregiver Experience CAHPS: Health Promotion and Education NQF #5 AHRQ Survey R P P 6. Patient/Caregiver Experience CAHPS: Shared Decision Making NQF #5 AHRQ Survey R P P 7. Patient/Caregiver Experience CAHPS: Health Status/Functional Status NQF #6 AHRQ Survey R R R 8. Care Coordination/Patient Safety Risk-Standardized, All Condition Readmission* NQF #TBD CMS Claims R R P 9. Care Coordination/Patient Safety 10. Care Coordination/Patient Safety 11. Care Coordination/Patient Safety 12. Care Coordination/Patient Safety Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator (PQI) #5) Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility NQF #275 AHRQ Claims R P P NQF #277 AHRQ Claims R P P CMS NQF #97 AMA PCPI/NCQA EHR Incentive Program Reporting R P P 13. Care Coordination/Patient Safety Falls: Screening for Fall Risk NQF #101 NCQA * This measure has been under development and finalization of this measure is contingent upon the availability of measures specifications before the establishment of the Shared Savings Program on January 1, Source: Centers for Medicare & Medicaid Services. 42 CFR Part 425. October 20, 2011.

7 Appendix: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings Domain AIM: Better Health for Populations 14. Preventive Health Influenza Immunization NQF #41 AMA- PCPI 15. Preventive Health Pneumococcal Vaccination NQF #43 NCQA 16. Preventive Health Adult Weight Screening and Follow-up NQF #421 CMS 17. Preventive Health Tobacco Use Assessment and Tobacco Cessation Intervention NQF #28 AMA- PCPI 18. Preventive Health Depression Screening NQF #418 CMS 19. Preventive Health Colorectal Cancer Screening NQF #34 NCQA GPRO Web Interface R R P 20. Preventive Health Mammography Screening NQF #31 NCQA GPRO Web Interface R R P 21. Preventive Health 22. At Risk Population - Diabetes 23. At Risk Population - Diabetes 24. At Risk Population - Diabetes 25. At Risk Population - Diabetes Measure Title Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years Diabetes Composite (All or Nothing Scoring): Hemoglobin A1c Control (<8 percent) Diabetes Composite (All or Nothing Scoring): Low Density Lipoprotein (<100) Diabetes Composite (All or Nothing Scoring): Blood Pressure <140/90 Diabetes Composite (All or Nothing Scoring): Tobacco Non Use NQF Measure #/ Measure Steward CMS GPRO Web Interface R R P Method of Data Submission Pay for Performance Phase In R = Reporting P=Performance Year 1 Year 2 Year 2 Source: Centers for Medicare & Medicaid Services. 42 CFR Part 425. October 20, 2011.

8 Appendix: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings Domain AIM: Better Health for Populations 26. At Risk Population - Diabetes 27. At Risk Population - Diabetes 28. At Risk Population Hypertension 29. At Risk Population Ischemic Vascular Disease 30. At Risk Population Ischemic Vascular Disease 31. At Risk Population - Heart Failure 32. At Risk Population Coronary Artery Disease 33. At Risk Population Coronary Artery Disease Measure Title Diabetes Composite (All or Nothing Scoring): Aspirin Use Diabetes Mellitus: Hemoglobin A1c Poor Control (>9 percent) NQF #59 NCQA Hypertension (HTN): Blood Pressure Control NQF #18 NCQA Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL Control <100 mg/dl Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) NQF Measure #/ Measure Steward NQF #75 NCQA NQF #68 NCQA NQF #83 AMA- PCPI NQF #74 CMS (composite) /AMA- PCPI (individual component) NQF # 66 CMS (composite) /AMA- PCPI (individual component) Method of Data Submission Pay for Performance Phase In R = Reporting P=Performance Year 1 Year 2 Year 2 GPRO Web Interface R R P GPRO Web Interface R R P GPRO Web Interface R R P Source: Centers for Medicare & Medicaid Services. 42 CFR Part 425. October 20, 2011.

Medicare Shared Savings Program Quality Measure Benchmarks for the 2014 and 2015 Reporting Years

Medicare Shared Savings Program Quality Measure Benchmarks for the 2014 and 2015 Reporting Years Introduction This document describes methods for calculating the quality performance benchmarks for Accountable