CMS Announces New Accountable Care Organizations in Massachusetts

Two out of the first 27 accountable care organizations (ACO’s) in CMS’ new Shared Savings Program reside in Massachusetts and will be online with its counterparts from across the country this month.

According to a press release by CMS, “The selected organizations have agreed to be responsible for improving care for nearly 375,000 beneficiaries in eighteen states through better coordination among providers.”

The CMS statement continues that all ACOs that succeed in providing high quality care may share in the savings to Medicare, as long as their performance reduces the cost of care and is sufficiently rated on 33 quality measures. The quality measures relate to, among other things, care coordination and patient safety, use of appropriate preventive health services, improved care for at-risk populations, and the patient experience of care.

The Massachusetts ACO’s include Jordan Community ACO and Physicians of Cape Cod AC. CMS provides summaries of each ACO and the Massachusetts initiatives are described here:

  • The Jordan Community ACO is a not-for-profit organization based in Plymouth, Massachusetts and founded in 2012. The Jordan Community ACO consists of more than 100 physicians from Plymouth Bay Medical Associates, Jordan Physician Associates, and a number of specialty physicians from Jordan Hospital. Together, the Jordan Community ACO physicians coordinate the healthcare of more than 6,000 Medicare beneficiaries in Plymouth and Barnstable Counties. This approach ensures that patients receive the right care from the right provider at the right time, making it possible to identify and address problems early, before hospital care becomes necessary.
  • Physicians of Cape Cod ACO has been coordinating care for beneficiaries through a managed care program for 10 years, and intends to bring the expertise developed in that program to the ACO model for fee-for-service beneficiaries. It is expected to serve approximately 5,000 beneficiaries living in Cape Cod, Massachusetts.

Five of the 27 ACO’s are also participating in the Advance Payment ACO program, although none of them are in Massachusetts. One project is located in northern New Hampshire and called the North Country ACO. These 27 ACO’s join the 32 “Pioneer ACO’s” that have 5 projects in Massachusetts.

CMS revealed they are reviewing 150 additional applications for the Medicare Shared Savings Program, of which more than 50 are aiming to be in the Advance Payment Model.

More information is available in CMS’ announcement.

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HCA Informs Members on Pioneer ACO and Independence at Home Programs

The Home Care Alliance held a well-attended conference call to inform members about two major programs recently announced by CMS:

First, the Department of Health and Human Services announced the first 32 organizations in 18 states that will participate in the new Pioneer Accountable Care Organization (ACO) initiative. This program is operated by the CMS Innovation Center under Section 3022 of the Affordable Care Act. Selected Pioneer ACOs include “physician-led organizations and health systems, urban and rural organizations, and organizations in various geographic regions of the country.” Five of those organizations are in Massachusetts:

  • Atrius Health Services
  • Beth Israel Deaconess Physician Organization
  • Mount Auburn Cambridge Independent Practice Association (MACIPA)
  • Partners Healthcare
  • Steward Health Care System

This Pioneer ACO Presentation was given by HCA Executive Director Pat Kelleher on the call and explains some of the points that home care agencies should be aware of as the initiative moves forward.

The CMS Center for Innovation also has a site full of resources on Pioneer ACO’s including FAQ’s and brief summaries of the selected ACO’s.

WBUR’s CommonHealth Blog had a feature on Pioneer ACO’s and asked each of the five accepted systems in Massachusetts what the program will mean for patients.

The second program announced was a solicitation for the new Independence at Home Demonstration Program (IAH), which aims to test a service delivery model that utilizes physician and nurse practitioner-directed primary care teams to provide services to certain Medicare beneficiaries with multiple chronic illnesses in their homes.

HCA also gave this presentation on the Independence at Home Demonstration on the conference call for members to explain that home care agencies can be a major partner to physician practices, despite the fact that the program is directed by a physician or nurse practitioner-led practice with experience in making home visits.

The IAH Demonstration’s webpage also has FAQ’s as well as the solicitation and application.

The Alliance will pass along any more information as it becomes available.

Return to www.thinkhomecare.org.

 

State Seeks Comments on Accountable Care Organizations Through New RFI

The state’s Executive Office of Health and Human Services has released a Request for Information regarding the formation of Accountable Care Organizations (ACO’s) and are seeking comments from “all interested partComm-PASS logoies.”

The RFI includes an introductory letter from Health and Human Services Secretary Dr. JudyAnn Bigby and a thorough explanation of the state’s intentions for the transition to a new payment system. A response template is included in “Attachment A” of the document and comments should be submitted electronically through the Commonwealth Procurement Access and Solicitation System (Comm-PASS). Instructions are available in the RFI and the Home Care Alliance encourages home care agencies to submit comments as they see fit.

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Hearing Kicks-off Public Comment Period on Payment Reform

A packed hearing in the State House’s Gardner Auditorium on Monday kick-started the conversation on what is likely to be the biggest change in the Massachusetts health care delivery system since the state passed universal coverage in 2006.

The Governor’s payment reform legislation would move the system of paying for all health care in the state from a fee-for-service model to more of a global payment model, with accountable care organizations responsible for delivering quality care in a manner that slows the growth of spending.

Much of the testimony and discussion is centering on how prescriptive the legislation will be in terms of mandatory versus voluntary participation, and the composition and authority of various oversight boards and advisory committees. Rey Spadoni, President & CEO of the Visiting Nurse Association of Boston and James Fuccione of the Home Care Alliance presented testimony regarding the need to recognize the importance of including the full continuum of care in any ACO model and central role that home care can play in a system that becomes more patient-centered, more cost conscious and accountable.

The Alliance, in particular, has asked in its testimony that the legislation be amended to require at least one home health/post-acute provider to be included on every ACO’s governing body.  The VNAB testimony asked that the new model recognize home health’s “investments in technology, clinical centers of excellence that serve patients with chronic disease, staff training and the addition of support services designed to keep people at home and independent or achieving the highest quality of life levels possible for them.”

The Home Care Alliance strongly encourages every interested agency to submit written testimony, which can be sent to the Alliance to collect and forward on to the Joint Committee on Health Care Financing, or to show up at public hearings being held across the state at the dates below:

  • Monday, May 23 at 11:00 a.m. at UMASS Medical School, Worcester (55 Lake Avenue North, 6th Floor of the medical school, Amphitheatre 3)
  • Monday, June 6 at 11:00 a.m. at Salem State University, Salem (71B Loring Avenue, Central Campus, Marsh 210)

The Alliance needs members to offering verbal or written comments if we are to be successful in carving an explicit role for home care into the ACO model.

The Home Care Alliance previously released a position paper on ACO’s prior to the Governor’s legislation that can be used to guide comments.

Return to www.thinkhomecare.org.

CMS Releases Proposed Rule on ACOs

A proposed rule has been released by the Centers for Medicare and Medicaid Services (CMS) for comment regarding the formation of Accountable Care Organizations or ACO’s, which create incentives for health care providers to work together to treat an individual patient across care settings.

Section 3022 of the Affordable Care Act created the Medicare Shared Savings Program that is intended to encourage providers of services and suppliers to create a new type of health care entity, which the statute calls an Accountable Care Organization. The proposed rule mentions home health, but it is important that comments on the rule are submitted to ensure that home health agencies are active participants in every ACO. Given the ACO initiative’s mission of caring for patients more efficiently and at a lower cost, this is an excellent opportunity for agencies to speak up.

The proposed rule was released on March 31 and comments will be accepted by CMS for 60 days.  You can comment:

  • By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1345-P,
P.O. Box 8013,
Baltimore, MD 21244-8013.

Below is the full announcement from CMS on the Medicare Shared Savings Program that includes a summery of the Affordable Care Act provision on ACO’s and some information from the proposed rule.

SUMMARY OF PROPOSED RULE PROVISIONS FOR ACCOUNTABLE CARE ORGANIZATIONS UNDER THE MEDICARE SHARED SAVINGS PROGRAM

Overview

On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

In developing the proposed rule, CMS has worked closely with agencies across the Federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Medicare Shared Savings Program (Shared Savings Program).

This fact sheet describes the proposals addressing the proposals for what ACOs are, how they can be created, and other general topics.  CMS has posted separate fact sheets on its web site to address in greater detail specific aspects of the proposed rule, such as the quality measures and performance scoring.

There will be a 60 day public comment period on this proposed rule. CMS encourages all interested members of the public, including providers, suppliers, and Medicare beneficiaries to submit comments so that CMS can consider them as it develops final regulations on the program.

Background:

Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012.  This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO)” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending.  Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

ACOs and the Medicare Beneficiary:

An ACO provides an opportunity for Medicare beneficiaries to receive high quality evidence-based health care that eliminates waste and reduces excessive costs through improved care delivery.   However, there would be significant differences between ACOs, as described in the proposed rule and the private managed care plans offered under the Medicare Advantage program.  Beneficiaries would not enroll in a specific ACO.  Instead the proposed rule calls for Medicare to take a retrospective look at the beneficiary’s use of services to determine whether a particular ACO should be credited with improving care and reducing expenditures.  This means that an ACO would have an incentive to improve the quality of care for all patients seen by its member providers and suppliers.

The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care.  The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO.

The proposed rule would also require each provider in an ACO to notify the beneficiary that the beneficiary’s claims data may be shared with the ACO. This data sharing is intended to make it easier to coordinate the beneficiary’s care; however, the provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO.  The provider must give the beneficiary the opportunity to opt-out of those data sharing arrangements.  For Medicare beneficiaries who choose not to opt-out of the data sharing arrangements, the proposed rule would limit data sharing to the purposes of the Shared Savings Program and would require compliance with applicable   privacy rules and regulations, including the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Proposed eligibility requirements for an ACO:

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, instead of the fragmented care that has so often been part of fee-for-service health care.  The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

  • ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements,
  • Networks of individual practices of ACO professionals,
  • Partnerships or joint ventures arrangements between hospitals and ACO professionals, or
  • Hospitals employing ACO professionals.
  • Other Medicare providers and suppliers as determined by the Secretary

In the proposed rule, the Secretary has used her discretion to add certain critical access hospitals as eligible to participate in the Shared Savings Program.

The statute also requires each ACO to establish a governing body representing ACO providers of services and suppliers and Medicare beneficiaries. The proposed rule would make each ACO responsible for routine self-assessment, monitoring and reporting of the care it delivers.

To participate in the Shared Savings Program, the proposed rule would require an ACO to complete an application providing the information requested by CMS, including how the ACO plans to deliver high quality care at lower costs for the beneficiaries it serves.  As proposed, the ACO must agree to accept responsibility for at least 5,000 beneficiaries.  If the application is approved, the ACO must sign an agreement with CMS to participate in the Shared Savings Program for a period of three years.   An ACO will not be automatically accepted into the Shared Savings Program.

The proposed rule outlines a monitoring plan that includes analyzing claims and specific financial and quality data as well as the quarterly and annual aggregated reports, performing site visits, and performing beneficiary surveys.

Under the proposed rule, there are a number of circumstances under which CMS may terminate the agreement with an ACO, including avoidance of at risk beneficiaries and failure to meet the quality performance standards.

Tying payment to improved care at lower cost:

Under the proposed rule, Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems.  The proposed rule would require CMS to develop a benchmark for savings to be achieved by each ACO if the ACO is to receive shared savings, or be held liable for losses.  Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to receive any shared savings.

The proposed rule would establish quality performance measures and a methodology for linking quality and financial performance that will set a high bar on delivering coordinated and patient-centered care by ACOs, and emphasize continuous improvement around the three-part aim of better care for individuals, better health for populations, and lower growth in expenditures.  The proposed rule would require the ACO to have in place procedures and processes to promote evidence-based medicine and beneficiary engagement in their care.  The proposed rule would require ACOs to report quality measures to CMS and give timely feedback to providers.  CMS expects that ACOs will invest continually in the workforce and in team-based care. To assure program transparency, the proposed rule would require ACOs to publicly report certain aspects of their performance and operations.

Under the proposed rule, an ACO that meets the program’s quality performance standards would be eligible to receive a share of the savings it generates below a specific expenditure benchmark that would be set by CMS for each ACO. The proposed rule would also hold ACOs accountable for downside risk by requiring ACOs to repay Medicare for a portion of losses (expenditures above its benchmark). To provide an entry point for organizations with varied levels of experience with and willingness to take on risk, the proposed rule would allow an ACO to choose one of two program tracks.  The first track would allow an ACO to operate on a shared savings only track for the first two years, but would then require the ACO to assume the risk for shared losses in the third year.  The second track would allow ACOs to share in savings and risk liability for losses beginning in their first performance year, in return for a higher share of any savings it generates.

The Shared Savings Program NPRM will appear in the April 7, 2011 issue of the Federal Register.  CMS will accept comments on the proposed rule until June 6, 2011, and will respond to them in a final rule to be issued later this year.  The Shared Savings Program will begin operating on January 1, 2012.

Please Note: Once the regulation is published on (April 7, 2011) the preceding link will be deactivated and the published version of the regulation will be available on the National Archives website at

http://www.archives.gov/federal-register/news.html.

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IMPROVING QUALITY OF CARE FOR MEDICARE PATIENTS: ACCOUNTABLE CARE ORGANIZATIONS

On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

This fact sheet describes the proposals to ensure that ACOs provide high quality care, including proposed quality measures, and a proposed method for scoring the performance of the ACO for purposes of the Shared Savings Program. There will be a 60 day public comment period on this proposed rule. CMS encourages all interested members of the public, including providers, suppliers, and Medicare beneficiaries to submit comments so that CMS can consider them as it develops final regulations on the program.

Background:

The Medicare Shared Savings Program, which is to be implemented on January 1, 2012, is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to coordinate patient care and improve communications with each other to get each beneficiary the right care at the right time, and see that the care is provided right the first time.  To accomplish this, the Act allows providers to create ACOs that will be held accountable for improving the health and experience of care for individuals, improving the health  of populations, and reducing the rate of growth in health care spending.  Studies show that better care often costs less, because coordinated care helps avoid unnecessary duplication of services and preventing medical errors.

Proposals For Assessing Quality Included in the ACO Proposed Rule:

Proposed Quality Measures:  For 2012, CMS proposes to use a number of quality measures to establish the quality performance standard ACOs must meet in order to share in savings, provided they also meet the program’s cost savings requirement. These 65 measures span five quality domains: Patient Experience of Care, Care Coordination, Patient Safety, Preventive Health, and At-Risk Population/Frail Elderly Health.   The list of proposed measures is included in the appendix to this fact sheet.

CMS considered a broad array of process and outcome measures would help in assessing an ACO’s success in delivering high-quality health care at both the individual and population levels.  Several of the proposed quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System, the Electronic Health Record (EHR) Incentive Program, and the Hospital Inpatient Quality Reporting Program. CMS also sought to align the proposed ACO quality measures with the National Quality Strategy and other Department of Health and Human Services priorities.  CMS proposes that the measures would be reported to CMS through a combination of claims submission, data collection using a tool designed for clinical quality measure reporting, and surveys.

CMS is proposing to define the first quality performance period as beginning January 1, 2012 and ending December 31, 2012.

Proposed Quality Performance Scoring:

As required by the Affordable Care Act, before an ACO can share in any savings created, it must demonstrate that it is delivering high quality care.  Thus, a calculation of the quality performance standard will indicate whether an ACO has met the quality performance goals that would allow it to be considered eligible for shared savings.  The proposed method for scoring the measures and determining the performance level that must be achieved to share in savings under the Shared Savings Program is described in the proposed rule.

CMS proposes that the performance on each measure will be scored on a linear points scale and roll up into 5 scores for each of the 5 domains. The percentage of points earned for each domain will be aggregated using an equal weighting method to arrive at a single percentage that will be applied to the maximum sharing rate for which the ACO is eligible.
For the first year of the Shared Savings Program, CMS proposes to set the quality performance standard at the reporting level. This means that during the first performance period, ACOs will be required to report the quality measures completely and accurately in order to share in savings. However, CMS proposes to still score quality in the first year for informational purposes and to help define the benchmarks for future program years. CMS proposes to set the quality performance standard at a higher level in subsequent years.

Proposed Incorporation of the Physician Quality Reporting System into the Shared Savings Program:

The Affordable Care Act allows CMS to incorporate the Physician Quality Reporting System reporting requirements and incentive payments into the Shared Savings Program. ACO participant providers/suppliers who are also Physician Quality Reporting System eligible professionals may earn the Physician Quality Reporting System incentive as a group practice under the Shared Savings Program, by meeting its quality performance standard

The Shared Savings Program NPRM will appear in the April 7, 2011 issue of the Federal Register.  CMS will accept comments on the proposed rule until June 6, 2011 and will respond to them in a final rule to be issued later this year.  The Shared Savings Program will begin operating on January 1, 2012.

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