Download as PDF

Newsletter November 9, 2017

Table of Contents

NAACOS Announces 2018 Educational Events
Highlighting the PY2016 Results
Success Stories
IAC – First Survey
New Next Gen ACO Option to Remove Truncation Thresholds
CMS Releases Final 2018 QPP Rule
NAACOS Upcoming MACRA Webinar Series
CMS Releases 2018 Final Medicare PFS
ACO Deadline to Post Performance Results
BPCI Results Released
Difference Between Tracks that May Impact Financial Results
CMS Issues Payment Rules for 2018
MedPAC Discusses Primary Care and Psychiatric Care Payments
MACRA Hearing in Energy and Commerce B-CAPA
Maximize Membership by Accessing Policy Resources

NAACOS Announces educational events for 2018
New ACO Boot Camp, February 12-13 in Orlando
NAACOS new boot camp on Mastering Your Benchmark, Risk, and Data for Financial Success will give ACO executives a deep understanding of key factors that determine an ACO’s success.  This day-and-a-half workshop will feature noted experts in ACO operations and will include didactic presentations along with lab-style learning where ACOs can dig into their challenges and customize solutions proven to succeed. 

The boot camp is for ACOs of all types that want to:

  • Understand and operationalize the benchmark calculation
  • Measure and manage their risk score
  • Get the most from their data and reports
  • Create an actionable plan for their ACO’s financial success 

With a small classroom format, this boot camp will enable brand-new ACOs to get a head start on designing processes that lead to success. More experienced ACOs will also benefit from this opportunity to examine and refine current practices under the guidance of experts.  Space is limited, and registration is restricted to ACO employees.  Register Today! 

Register NOW for NAACOS Spring 2018 Conference, April 25-27 in Baltimore
The NAACOS Spring Conference promises to be our biggest and most important event to date with more than 600 ACO executives and a rich agenda on the most critical issues for ACOs in 2018.  In response to attendee feedback, we will be organizing sessions that focus on the needs of each track and holding “meet ups” for the tracks to network with peers and learn from experts on their track’s top issues. Visit our website for more information on the conference. 

Welcome New ACO Member 

UC Davis Health ACO
Sacramento, CA

 

HIGHLIGHTING THE 2016 PERFORMANCE RESULTS
On October 27, CMS released the detailed PY 2016 results for the Medicare Shared Savings Program (MSSP) through a Public Use File available here. This follows the release of the 2016 results for ACO models operated through the Center for Medicare and Medicaid Innovation, which are available on this webpage. NAACOS responded to these 2016 results in this press release, and we also compiled a brief summary of the latest results called, 2016 Medicare ACO Results: Highlights. The overall amount of savings and the proportion of those qualifying for earned shared savings reflects the deep commitment ACOs have to changing how care is delivered and demonstrates positive results for the beneficiaries served. This sends a strong message about the role of accountable care models and the significant contributions to Medicare. NAACOS is pleased to see that the hard work of ACOs continues to reduce spending while improving quality of care. Plus, NAACOS members continue to stand out from the rest! The highlight document showcases the strong performance ACOs have accomplished in savings and quality and is a great resource for your board and stakeholders.

CHECK OUT YOUR COLLEAGUE’S SUCCESS
Thank you to the ACOs who have shared their press releases on PY2016 results! If you haven’t yet, take a look at your colleague’s success stories at NAACOS Members PY2016 Press Releases. We’re still welcoming new additions for this valuable resource providing a quick view of national successes. 

Please send a link to your press release or any announcements you may have to [email protected]. It’s great to celebrate together! 

INSTITUTE FOR ACCOUNTABLE CARE – FIRST SURVEY
We invite you to participate in the Institute for Accountable Care’s inaugural survey! Want to know how ACOs coordinate care for complex patients? Interested in learning more? We are too! Launched with initial funding from NAACOS, the Institute’s mission is to put research to work at the front line of accountable care. This survey is part of a research effort to identify strategies to improve care for individuals with complex health care conditions. The project is funded by The SCAN Foundation and more information can be found in the project’s press release. The online survey should take around 15 minutes and can be accessed at: http://sgiz.mobi/s3/Institute-for-Accountable-Care For questions, please contact Teresa Litton. 

NEW NEXT GENERATION ACO OPTION TO REMOVE TRUNCATION THRESHOLDS
CMS has made an option available to the Next Generation ACOs such that they can now make an election as to whether they would like expenditures capped at the 99th percentile or would prefer to go “uncapped.” This option was available under the Pioneer Model and is now being made available in the Next Generation ACO Model. If elected, this change would be effectuated through an amendment to the Next Generation Participation Agreement. This option will be available for 2017 and 2018; 2019 and 2020 are the option years of the model and will be governed under a new participation agreement. As a reminder, all Next Generation ACOs are required to have in place a financial guarantee equivalent to 2 percent of their baseline expenditures.  If the ACO elects to go capped it will be 2 percent of capped baseline expenditures; if the ACO elects to go uncapped it will be 2 percent of uncapped baseline expenditures, therefore requiring the ACO to have a more valuable repayment mechanism in place. 

CMS RELEASES FINAL 2018 QUALITY PAYMENT PROGRAM RULE
CMS recently released the final rule outlining 2018 performance year policies for the Quality Payment Program (QPP), which corresponds with 2020 payment adjustments for Medicare Part B payments. A link to the final rule is available here along with this CMS factsheet. NAACOS issued a press release in response to the final rule, which is available here. Below is a summary of key changes in the rule, and NAACOS is developing a more comprehensive summary that will be available in the near future along with our webinars on the final QPP rule detailed in the article below. 

Advanced Alternative Payment Model (Advanced APM) Policies
CMS includes the Medicare Shared Savings Program (MSSP) Tracks 1+, 2 and 3 as well as the Next Generation ACO Model and the two-sided Comprehensive End Stage Renal Disease (ESRD) Care Model as Advanced APMs for 2018 performance. CMS estimates that approximately 185,000 to 250,000 eligible clinicians (ECs) will be eligible to qualify for Advanced APM bonuses in 2020 based on 2018 performance. Among other things, the final rule:

  • Finalized the proposal to maintain the revenue-based nominal amount standard at 8 percent of the average estimated total Medicare Parts A and B revenue of all providers and suppliers in participating APM Entities for the 2019 and 2020 Qualifying Provider (QP) Performance Periods.
  • Added flexibility to allow new Advanced APMs that start during a performance year to have an opportunity to qualify for Advanced APM bonuses as long as they participate for at least 60 continuous days during the performance period.
  • Discusses creating a demonstration in 2018 for clinicians not participating in Medicare APMs but who are participating in Medicare Advantage APMs, which would allow them to qualify for Advanced APM bonuses based on Medicare Advantaged Advanced APM participation alone.
  • Added a revenue-based nominal risk standard of 8 percent for the All-Payer Combination Option, which begins with the 2019 performance year.
  • Finalized a complex process for Other-Payer Advanced APM and QP Determinations that would:
    • Annually determine whether an Other-Payer arrangement qualifies as Advanced.
    • Allow payers or clinicians to submit information for Other-Payer Advanced APM determinations, through a complicated, likely time-consuming process.
    • Allow ECs and APM Entities to request a QP determination at the individual or APM Entity level, respectively.
  • Finalized the proposal to remove size limit requirements (50 ECs of less) for practices in Comprehensive Primary Care Plus (CPC+) Round 1 qualifying for the Advanced APM bonus.
  • Lowered the nominal risk standard for Medical Home Models for 2018, keeping it at 2.5 percent and raising it gradually in future years. 

Merit-Based Incentive Payment System (MIPS) Policies
MSSP Track 1 ACOs and ACOs that are in Advanced APM tracks/models but do not meet Qualifying APM Participant thresholds are subject to MIPS requirements. CMS estimates approximately 622,000 clinicians will be subject to MIPS in PY 2018. As a result of CMS’s policies for 2018, it is likely that MIPS bonus opportunities will remain limited for 2020 payments, even for the highest performers. Figure A (page 809) in the final rule estimates that those scoring 100 points (maximum possible points) in MIPS will receive only a 2.05 percent bonus in 2020. Those scoring at or above the exceptional performance threshold of 70 points would earn between 1 and 2.05 percent bonuses according to Figure A’s projections. Among other things, the final rule includes the policies below. The final rule:

  • Finalized a fairly low performance standard for MIPS participation with the MIPS performance threshold set at 15 points and the exceptional performance threshold remaining the same (70 points).
  • Changed the low volume threshold to allow more ECs the opportunity to meet the threshold and therefore be exempt from MIPS reporting (from $30k/100 or fewer patients in 2017 to $90k/200 or fewer patients in 2018).
  • Maintained a 90-day reporting period for the Advancing Care Information performance category and allows for continued use of 2014 Certified Electronic Health Record Technology.
  • Added MIPS bonus points for eligible clinicians deemed to be caring for more complex patients, based on hierarchical condition category (HCC) coding and dual eligibility status.
  • Included policy changes to benefit small practices, such as the increased low volume threshold, bonuses for eligible clinicians in small practices and introduction of a new virtual group option
  • Added a fourth snapshot date to determine which ECs are participating in the ACO for purposes of MIPS APM Scoring Standard evaluation. This additional snapshot date will occur on December 31.
  • Added the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for ACOs Survey in the MIPS quality performance score analysis for PY 2018.
  • Provides an opportunity for additional points to be earned for quality improvement year over year in MIPS. 

DON’T MISS OUR UPCOMING MACRA WEBINAR SERIES
NAACOS will host a two-part webinar series to review key changes to Medicare Access and CHIP Reauthorization Act (MACRA) QPP policies for 2018. Don’t miss these educational opportunities, which are free for NAACOS members! 

2018 Final QPP Rule: Advanced APMs
November 30 from 2:00 to 3:00 pm Eastern
On November 2, 2017 CMS released the final 2018 QPP rule. In this webinar, NAACOS staff will review changes made in the recent rule that affect ACOs participating in Advanced APMs, which includes MSSP Tracks 1+, 2 and 3, as well as the Next Generation ACO Model and the two-sided Comprehensive End Stage Rena Disease Care Model. This presentation will also address Advanced APM FAQs for the current performance year, will provide an outlook for the future growth of Advanced APMs, and will allow an opportunity for ACOs to ask questions and provide feedback related to the Advanced APM track of the QPP. 

2018 Final QPP Rule: MIPS for ACOs
December 7 from 2:00 to 3:00 pm Eastern
In this webinar, NAACOS staff will review changes made to the MIPS for the 2018 performance year in the final 2018 QPP rule. The presentation will focus on how MIPS applies to ACOs specifically through the APM Scoring Standard. 

Please register for these webinars in advance on our website. 

CMS RELEASES 2018 FINAL MEDICARE PHYSICIAN FEE SCHEDULE
On November 2, 2017 CMS released the final 2018 Medicare Physician Fee Schedule (PFS). The final regulation contains a number of important Medicare Part B payment and policy changes affecting ACOs including:

  • Modifications to MSSP beneficiary assignment methodology related to services furnished by Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs),
  • Changes to the ACO quality validation audit process,
  • Alleviating certain burdens associated with MSSP and Skilled Nursing Facility (SNF) 3-Day Rule Waiver applications,
  • Creating new billing codes for care coordination services and payments for RHCs and FQHCs for these services, and
  • Reductions to PFS payment rates for select items/services furnished by certain off-campus hospital outpatient provider-based departments. 

For more information on these important policy proposals, access our summary here. For more information, please access our Medicare Physician Fee Schedule webpage. 

ACO DEADLINE TO POST PERFORMANCE RESULTS
The public reporting deadline for ACOs to post 2016 performance results is Friday, December 1. ACOs should have received their pre-populated public reporting template accompanied by instructions from CMS on October 31. These were sent to ACO executives, and CMS instructs ACOs to contact their CMS coordinator through the Shared Savings Program mailbox should you have any questions about this process at [email protected]. 

BPCI RESULTS RELEASED
The Bundled Payments for Care Improvement (BPCI) initiative tests four models linking provider payments for a clinical episode of care to determine whether bundled payments can reduce Medicare payments while maintaining or improving quality of care. CMS recently posted the third program evaluation for the BPCI demonstration. While the evaluation, completed by the Lewin Group, found modest decreases in average spending for joint replacement, the authors also highlighted multiple issues with determining the true impact of this demonstration. Chief among them was the fact that providers simultaneously participated in multiple initiatives, making it difficult to determine who was ultimately responsible for any savings achieved. This is an issue NAACOS has highlighted repeatedly to CMS. More information on BPCI is available on the Innovation Center website. The full evaluation is available here. 

DIFFERENCES BETWEEN MEDICARE ACO TRACKS THAT MAY IMPACT ACO FINANCIAL RESULTS
As part of recent efforts to analyze the components of the various Medicare Shared Savings Program (MSSP) ACO tracks, NAACOS recently commissioned a white paper by Milliman, an actuarial and consulting firm. This paper, Differences Between Medicare ACO Tracks that May Impact ACO Financial Results, compares the tracks and is exclusively available to NAACOS members here. In addition to the paper, NAACOS created an interactive table, accessible on this webpage, for ACOs to input their own projected values to illustrate savings and losses under the various tracks.  

As ACOs consider participation options, it is critical to have the necessary information to weigh the various tracks. Important factors that ACOs must evaluate include the sharing percentages, savings and loss limits, and various differences between prospective versus retrospective beneficiary assignment, including the number of assigned beneficiaries, leakage, and care management opportunities. These and other factors are each important alone; but they also interact with one another, creating a dynamic set of considerations for ACOs to analyze as part of their decision-making process. We hope the paper and table help support ACOs’ understanding of the various tracks and their components, each of which provides certain opportunities and limitations. 

We plan on developing a more thorough paper in the near future that will include a deeper dive into the different ACO tracks/models, and we will evaluate data to help us shape policy recommendations for ensuring all models/tracks are fair and enable ACO success. 

CMS ISSUES PAYMENT RULES FOR 2018
CMS recently issued a number of final payment rules for 2018. On November 1, CMS issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) final rule, increasing the OPPS payment rates by 1.35 percent for 2018. The change is based on the hospital market basket increase of 2.7 percent minus both a 0.6 percentage point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law. After considering all other policy changes under the final rule, CMS estimates an overall impact of 1.4 percent payment increase for providers paid under the OPPS in CY 2018. Also released November 1 was the Ambulatory Surgical Center (ASC) Payment System. CMS updates ASC payments annually by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U). For CY 2018, the CPI-U update is 1.7 percent. More information on these rules is available on the CMS fact sheet. 

CMS also issued a final rule that updates the CY 2018 Medicare payment rates and the wage index for Home Health Agencies (HHAs) and projects that Medicare payments to HHAs in CY 2018 will be reduced by 0.4 percent, or $80 million, based on the finalized policies. More information is available on the CMS fact sheet.

MEDPAC DISCUSSES PRIMARY CARE AND PSYCHIATRIC CARE PAYMENTS
The Medicare Payment Advisory Commission (MedPAC) hosted a session last week titled “Rebalancing the Physician Fee Schedule Towards Primary Care.” The purpose of the session was to determine what factors are pushing more graduating medical school students into specialty care as opposed to primary care and psychiatric services. While other factors were cited, the inequity of PFS payments to specialists vs. primary care providers (PCPs) and psychiatrists was a major reason why the country has a shortage of both of these types of services. MedPAC wants to find ways of incentivizing providers to go into primary care and psychiatric practices. Slides from the session can be seen here. 

MedPAC staff asserted the fee schedule structure is inherently unbalanced against primary care because fee-for-service payments allow certain specialties to more easily increase volume of services than PCPs; primary care services are labor intensive and require more time thus greater efficiencies are harder to reach. 

Staff suggested to MedPAC’s commissioners the following policy questions to consider when reviewing possible approaches to address:

  1. Should Medicare increase payment rates for primary care services provided by all specialties or just primary care clinicians?
  2. Should payments also be increased for psychiatric services?
  3. How much should payments be increased?
  4. Should higher payments be distributed on a per service or a per beneficiary basis? 

The first approach was to increase fee schedule payments for primary care and psychiatric services provided by all specialties — higher payments would remain budget-neutral by offsetting the cost by lowering payments for other services and the increase paid on a per-service basis. Primary services would include evaluation and management (E&M) codes for office visits, home visits and visits to long-term care facilities providing chronic care management, transitional care management, welcome to Medicare visits and annual wellness visits. Psychiatric services would use the same E&M codes as well as psychiatric diagnostic evaluation and psychotherapy. 

The second approach was to increase payments for primary care and psychiatric services provided by certain clinicians. Clinicians would be eligible based on specialty designation (primary care or psychiatry) and their share of payments from primary care and psychiatric services. Three options for distributing the payment were presented:

  • Service by service because it’s easier to administer and rewards clinicians who provide more discrete primary care visits; or
  • Per beneficiary — however this could eventually bring issues about attribution and risk adjustment; or    
  • A possible mix of both options by implementing sequentially. 

When the discussion portion of the session commenced, most Commissioners agreed psychiatry reimbursement should be included in the rebalancing efforts. There was no consensus on who should receive the increase payments (MDs or mid-level providers, Psychiatrists vs. licensed clinical social workers, etc.), the amount of the increase or how the payments should be distributed. This will be further discussed at the next MedPAC meeting. 

MACRA HEARING IN ENERGY AND COMMERCE
The House Energy and Commerce Health Subcommittee hosted a hearing titled “MACRA and Alternative Payment Models: Developing Options for Value-Based Care.” Two panels testified before the committee – the first was the Chairman and Vice-Chairman of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), and the second consisted of physicians representing various medical groups. 

Overall, both PTAC and the doctors agree replacing the Sustainable Growth Rate (SGR) with MACRA has been a great catalyst for moving from fee-for-service (FFS) to value-based care. Both panels agreed on the speed bumps in implementing alternative payment models such as data sharing, provider collaboration, administrative burdens and potential up-front costs such as health information technology. 

The PTAC witnesses cited that the incentives MACRA provides plus the greater flexibility have led to many differing potential payment models from various types of organizations – primary care, specialists, large groups, small group, rural and urban. The PTAC chairman, Dr. Jeffrey Bailet, said APMs reward providers’ efforts and pays for services that traditional FFS does not. On the subject of risk, both witnesses agreed that assuming risk is not a one-size-fits-all solution, and PTAC, CMS and CMMI must be careful not to push too fast – there can be harmful unintended consequences such as a small rural hospital going out of business or providers closing a practice that are very hard to repair. 

The second panel gave several testimonials to how MACRA and APMs have affected their practices. Next Generation ACOs were represented by Dr. Daniel Varga, Chief Clinical Officer for Texas Health Resources who made several suggestions to how the MSSP program could be improved, all of them included in the pending ACO Improvement Act of 2017. 

Subcommittee Chairman, Dr. Michael Burgess closed the hearing saying, “It has been two and a half years since MACRA became law. I believe the true potential of MACRA has yet to be met, but I believe the law has already been proven a success in delivering better care to beneficiaries, savings to the Medicare program, and certainty to doctors. …Finally, it is critical that what we accomplish today follows the same open, transparent, and bipartisan structure that helped get MACRA signed into law.” 

For more information on today’s hearing, including a background memo, witness testimony, and archived webcast, click here.

IT’S ALMOST B-CAPA TIME
Coming soon! Tailored 2016 B-CAPA Reports will be sent to individual NAACOS ACO members in mid-December 2017. The goal of the Benchmarking Comparison and Performance Analysis (B-CAPA) Report is to provide actionable data for ACOs to evaluate their performance to comparable ACOs. The B-CAPA Report evaluates spending, utilization, and quality measures relative to various aggregate and regional “peer groups” of ACOs. The B-CAPA Reports also include summary charts, demographics, utilization, quality performance, actual quality score, and per-member-per-year analysis. Note: because the data is from CMS, the reports are exclusive to MSSP tracks. NAACOS is advocating for data to be made available for other programs as well. More information and examples of the B-CAPA report can be found on the B-CAPA webpage. 

MAXIMIZE YOUR NAACOS MEMBERSHIP BY ACCESSING OUR KEY POLICY RESOURCES
NAACOS members have full access to a broad range of educational resources developed to assist ACOs in understanding key policies that affect your organization’s efforts. Take advantage of the member exclusive resources that NAACOS has developed and updated over the last several months, including:

  • Differences Between Medicare ACO Tracks that May Impact ACO Financial Results: White Paper and Interactive Tool developed exclusively for NAACOS members.
  • Analysis of Projected ACO Scores in MIPS for 2017
  • NAACOS resource on preparing for a quality measures validation audit
  • NAACOS resource: The Impact of Retrospective Versus Prospective Attribution on Your ACO
  • NAACOS summary of the 2018 Proposed Quality Payment Program (QPP) Rule
  • NAACOS MACRA webinar series explaining CMS’ 2018 proposed changes to the Quality Payment Program (QPP)
  • NAACOS summary of the 2018 proposed Medicare Physician Fee Schedule Rule
  • NAACOS summary of the Proposed Rule to Cancel Cardiac and Expanded Joint Replacement Bundled Payment Models
  • Webinar: Telehealth & Remote Monitoring: Value to ACOs and Status of Reimbursement Changes in Washington
  • Webinar: Effective ACO Compliance Programs: Implementing & maintaining an effective compliance program for your ACO
  • Webinar: Using the SNF 3-Day Rule Waiver: Lessons Learned
  • Webinar: Overview of the Proposed 2018 Medicare Physician Fee Schedule Rule
  • NAACOS Overview of Research on ACO Performance (updated in October)
  • The ACO Guide to MACRA (updated in October)
  • NAACOS ACO Comparison Chart (updated in September) 

Additionally, we created new educational materials focused on spreading the word about ACOs, including their background and effects on quality, cost, etc. These materials are designed to introduce the ACO concept to new audiences and are available to the public and may be helpful as you engage with your community to explain the key mission of ACOs and highlight the great work you do every day for the patients you serve: