Center for Medicare and
Medicaid Services
•
Overview
•Beneficiary Attribution
•Payment Methodology
•Quality
•Data Sharing
•Governance
•Application Scoring
• To design ACO program for more advanced
systems
• The Pioneer ACO will complement the MSSP
ACO and inform MSSP ACO development
• Notice of Request for Applications (RFA):
Released
May 17
• Letter of Intent (and Data Use Agreement):
Due
June 30
to
[email protected]
• Pioneer ACO Model Application:
Postmarked on or before
August 19
CMS will only consider applications from
organizations that have submitted letters of intent
• Interview of Semi-Finalists:
1-2 months after
application deadline
• Program Tentative Start:
3
rdor 4
thquarter of 2011
(CMS says it will provide “comfortable interval”)
• Participation period of up to 5 years • Higher risk, higher reward
• More beneficiaries
• Can select prospective beneficiary attribution • Specialist involvement in attribution process
• Other payer involvement: in either year 2 or year 3 majority of all ACO revenue must come from
“outcomes-based contracts” (RFA is unclear)
Note: DGME excluded from payment
calculations, but IME, DSH, and all other
• Program to be administered by the CMS Center for Medicare and Medicaid Innovation (CMMI)
• Agreement Period: 3 years, with CMS to use its discretion to extend for 2 additional years
• Organizations may participate in a Medicare Shared Savings Program ACO (MSSP ACO) or a Pioneer ACO • CMMI expects to partner with 30 Pioneer ACOs, but
could be more
• Flexibility: CMS appears willing to work with individual ACOs and is open to ACO suggestions
• Pioneer ACOs have a minimum shared savings/loss rate of 1% and will share in first dollar savings
• Note: Pioneer ACOs that do not require FTC/DOJ
•
Overview
•
Beneficiary Attribution
•Payment Methodology
•Quality
•Data Sharing
•Governance
•Application Scoring
• Pioneer ACOs must have a minimum of 15,000
assigned beneficiaries (5,000 for rural Pioneer
ACOs)
MSSP ACO: minimum of 5,000 beneficiaries
• Pioneer ACOs can elect either
prospective
or
retrospective
beneficiary assignment
MSSP ACO: retrospective assignment
• For prospective attribution, CMS will identify
Pioneer ACO’s population through analysis of prior
3 years’ fee-for-service claims with the most recent
year weighted most heavily (60%, 30%, 10%)
• Beneficiaries will first be aligned with the group of primary care providers (same as MSSP, but including NPs and PAs) who billed for the plurality of primary care allowed charges during combined 3 year period
• If a beneficiary had less than 10% of E&M allowed charges billed by primary care physicians (in or out of the ACO),
alignment will be with the group of eligible specialists who billed for the plurality of allowed charges
• Eligible specialties: nephrology, oncology, rheumatology, endocrinology, pulmonology, neurology, and cardiology
•
Overview
•Beneficiary Attribution
•
Payment Methodology
•Quality
•Data Sharing
•Governance
•Application Scoring
• Multiple payment arrangements:
o
Core Payment Arrangement as set forth in RFA
• Core Arrangement, Core Option A, and Core
Option B
o
Alternative Payment Arrangements: CMS
encourages applicant Pioneer ACOs to propose
alternative payment models
• CMS will use these suggestions to develop
the Alternative Payment Arrangement(s)
which Pioneer ACOs can select
Performance Period 1 Performance Period 2 Performance Periods 3, 4, 5 Core Arrangement OR Up to 60% shared savings and shared losses
10% maximum
Up to 70% shared savings and shared losses
15% maximum
Population-based payment, with up to 70% shared savings and shared losses 15% maximum Core Option A Up to 50% shared
savings and shared losses
5% maximum
Up to 60% shared savings and shared losses
10% maximum
Same as Core Arrangement
Core Option B Up to 70% shared savings and shared losses
15% maximum
Up to 75% shared savings and shared losses
15% maximum
Population-based, up to 75% shared
savings and shared losses
15% maximum
Core Payment Arrangement
• Based on weighted prior 3 year average of actual
expenditures for each of ACO’s aligned beneficiaries, most recent year weighted most heavily (60%, 30%, 10%)
• This baseline will be increased by average percentage
growth rate (50%), and absolute dollar equivalent of growth rate (50%) for a national reference population (“matched cohort”)
o The national reference population will have beneficiary characteristics are similar to the Pioneer ACO’s
population
o It will be adjusted for age, sex, and potentially other characteristics
• If ACO generates a minimum annual average
savings over years 1 and 2 (which will vary
based on whether ACO is in a high or low cost
state):
o
Payment will transition to population-based
payment in year 3
• ACO providers will receive 50% of FFS
payment on submitted claims; the
remainder will be provided to the ACO as
per-beneficiary-per-month payment based
on projections
• “Pioneer ACOs must commit to entering outcomes-based contracts with other purchasers (private health plans, state Medicaid agencies, and/or self-insured employers) such that the majority of the ACO’s total
revenues (including from Medicare) will be derived from such arrangements, by the end of the second
performance period in December 2013.” -- RFA p.13
• Outcomes-based contracts: include financial
accountability, evaluate patient experience of care, and include substantial quality performance incentives
•
Overview
•Beneficiary Attribution
•Payment Methodology
•
Quality
•Data Sharing
•Governance
•Application Scoring
• Performance measures and quality incentive
calculations will be the same as in MSSP ACO
final rule
• Pioneer ACOs may with withdraw from the
program if they find the MSSP ACO final rule
quality requirements unacceptable
•
Overview
•Beneficiary Attribution
•Payment Methodology
•Quality
•
Data Sharing
•Governance
•Application Scoring
• Similar to MSSP but trying to provide more, and
more quickly
o
Offering flexibility, CMS will produce
additional reports based on Pioneer ACO’s
input
• Similar to MSSP, beneficiaries may opt out of
having their identifiable data shared with the
Pioneer ACO
o
At the beginning of each year, CMS and the
Pioneer ACO must notify beneficiaries
•
Overview
•Beneficiary Attribution
•Payment Methodology
•Quality
•Data Sharing
•
Governance
•Application Scoring
• Governing body must include “meaningful
representation” from consumer advocates and
patients
• Exception to consumer advocate/patient
requirement: extenuating circumstances, such
as existing legal restrictions
•
Overview
•Beneficiary Attribution
•Payment Methodology
•Quality
•Data Sharing
•Governance
•
Application Scoring
Application Scoring
Domains Selection Factors
(Examples)
Maximum Score Experience with risk sharing
and outcomes-based contracts
• % of patient revenues in risk sharing arrangements and outcomes based contracts
•Degree of financial risk in applicant’s 2 largest contracts as % of ACO’s revenues
•Applicant’s financial stability
25
Performance capabilities • Primary care capability
•HIT Infrastructure on provider and pop. level • Strength of community relationships
20
Potential for meeting triple aim
•Proposed care improvement plan
•Potential for cost savings, quality improvement
20
Leadership & management •Strength of executive credentials
•Leadership commitment
•Managerial and staff resources
20
Patient Centeredness •Ensuring patient access, care transitions
•Patient engagement and activation
10
