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Nebraska HIMSS 2019 Spring Meeting
Impact of ACOs on Rural Healthcare FacilitiesTodd Searls, Regional Vice President
Caravan Health
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Disclosure(s):
Todd Searls– I have no actual or potential conflict of interest in relation to this program/presentation.
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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
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Medicare Challenges Are Rural ChallengesMSSP OPPORTUNITIES ARE OPPORTUNITIES FOR CAHS/RHCS
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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
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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
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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
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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
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“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/
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.
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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
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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
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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%
1st dollar savings, rate of 40%
1st dollar savings, rate of 50%
1st dollar savings, rate of 75%
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
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PeopleRIGHT PERSON / RIGHT SEAT
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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
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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)
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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.
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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
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Technology2015 CEHR IS JUST THE STARTING POINT
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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
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• 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
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Analytics: Internal & External Data
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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
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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
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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.
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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.)
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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?
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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.
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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
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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.
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Todd Searls, RVP | [email protected] | 816.945.6341
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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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