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Newsletter November 07, 2018

Table of Contents

2018 Midterm Elections
CMS Releases Final 2019 MPFS and QPP Policies
HHS Floats New Model for Part B Drug Payments
Member Listserv
CMS Releases Payment Rules
CMS Issues Revised ACO-11 Perf. Scores
Geisinger Initiative Featured
ASPE RFI on Effect of SE Status on Qual Measures
CMS Updates Billing Req. for NextGen Home Visits
Extending 2018 Contract Requirements and Voluntary Termination Deadlines
New Pathways Resource Page
Member Resource on New Opioid Law
NAACOS Boot Camp
Updated Guidelines on Palliative Care
B-CAPA Reports
High-Low Revenue Analysis
Patient Stories Needed
I4AC Webinar
MedPAC Talks Changing AAPM Bonus
NAACOS Writes HHS on Anti-Kickback Changes
Spring 2019 Conference 


2018 MIDTERM ELECTIONS: DEMOCRATS TAKE HOUSE, REPUBLICANS RETAIN SENATE
The long anticipated 2018 midterm elections saw high voter turnout and a change in the party controlling the U.S. House of Representatives. Democrats exceeded the 218 seats needed to take control of the House, while Republicans will retain control of the Senate where they picked up two additional seats. The leadership change in the House will result in new chairs for key committees of jurisdiction over Medicare, including the Energy and Commerce Committee and Ways and Means Committee. NAACOS looks forward to continuing to work with lawmakers on both sides of the aisle to improve Medicare and protect and expand the role of ACOs in our healthcare industry. Voters in Utah, Idaho, and Nebraska passed ballot initiatives to expand Medicaid in their states, which will provide coverage to an estimated 325,000 people, who earn less than 133 percent of the poverty level. To learn more about the implications of the midterm elections, join us for a post-election analysis webinar November 12 at 2:00 pm ET. Register today! 


CMS RELEASES FINAL 2019 MEDICARE PHYSICIAN FEE SCHEDULE AND QPP POLICIES
Last week, the Centers for Medicare & Medicaid Services (CMS) released the final 2019 Medicare Physician Fee Schedule (MPFS) rule. This regulation includes policies affecting Medicare physician payment, Quality Payment Program (QPP) requirements for 2019, and important Medicare Shared Savings Program (MSSP) changes, including finalization of certain policies previously proposed in the Pathways to Success rule. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included annual 0.5 percent increases to the Medicare conversion factor through 2019. This increase as well as other statutory requirements and CMS’s final policies result in the projected conversion factor of $36.04 for 2019, which is a very minor increase from the $35.99 conversion factor in the 2018 final MPFS. NAACOS will hold a webinar on November 20 to walk through all the pertinent policy changes in this lengthy rule. Don’t wait – register today! 

Some of the key issues affecting ACOs include CMS’s policies to:

  • Allow ACOs that entered a first or second agreement period beginning on January 1, 2016, to voluntarily elect a six-month extension of their current agreement period for a fourth performance year from January 1, 2019, through June 30, 2019.
  • Modify the primary care services used in assigning beneficiaries to ACOs to reflect recent code changes and update voluntary alignment policies.
  • Extend policies providing relief for ACOs and their clinicians affected by extreme and uncontrollable circumstances during 2017 to performance year 2018 and subsequent years.
  • Revise documentation requirements related to Evaluation and Management (E/M) services.
  • Modify E/M payment, effective beginning in 2021, to pay a single rate for E/M office/outpatient visit levels 2, 3, and 4 (one for established and another for new patients).
  • Establish a 30-point performance threshold and 75-point exceptional performance threshold for the Merit Based Incentive Payment System (MIPS) track of the QPP.
  • Make changes to the MSSP quality measure set, including the removal of 10 quality measures and the addition of two Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures.
  • Expand the definition of MIPS eligible clinicians (ECs) to include physical therapists, occupational therapists, clinical psychologists, qualified speech language pathologists, audiologists and registered dieticians.
  • Modify the Advanced Alternative Payment Model (APM) requirement related to Certified Electronic Health Record Technology (CEHRT) to require at least 75 percent of ECs in each APM Entity to use CEHRT.
  • Update and refine certain standards and processes for the new, all-payer combination option allowing ACOs to earn credit for their participation in Advanced APMs outside of Medicare, including allowing multi-year submissions.
  • Maintain the revenue-based nominal amount risk standard for Medicare and Other Payer Advanced APMs at 8 percent through 2024.
  • Add the following codes to the list of telehealth services: HCPCS codes G0513 and G0514 (prolonged preventive service/s).
  • Make patients’ homes eligible sites to receive telehealth for the treatment for substance use disorders and co-occurring mental health disorders, beginning July 1, 2019. 

A link to the CMS factsheet for the physician fee schedule provisions is available here, and CMS issued a separate factsheet for the 2019 QPP policies, available here. NAACOS staff is currently reviewing the regulation and will provide a more thorough analysis to members shortly. 


HHS FLOATS NEW MODEL FOR PART B DRUG PAYMENTS
CMS is seeking feedback on a possible new way to pay for Medicare Part B drugs, which tops $28 billion annually. In an October 25 advanced notice of proposed rulemaking, CMS outlines a three-part plan: (1) tying what Medicare pays for certain Part B drugs to the average of what other industrialized countries pay; (2) allowing third-party, private-sector vendors to buy drugs and work with physicians and hospitals for business; and (3) doing away with Medicare’s paying providers the average sales price of a drug plus a 6 percent add-on payment (or 4.3 percent post-sequester) for administering Part B drugs. The regulation is here along with a CMS fact sheet and a question-and-answer blog. CMS is seeking feedback on a number of issues, including determining payments by drug class or medical practice type and how often this new, alternative add-on payment will be calculated. The deadline for comments is December 31. NAACOS is reviewing the proposed rule and its potential impact on ACOs and would appreciate you sharing your thoughts by emailing [email protected].  


Welcome New Member

Covenant ACO, Inc.
Lubbock, TX

NAACOS MEMBER LISTSERV CONNECTS ACO PEERS
The NAACOS listserv is exclusively for ACO members and allows you to send messages and ask questions through a single email to all subscribing members. Our new “Knowledge Base” gives listserv subscribers access to a searchable archive of all previously asked questions and answers. All member ACOs may use the listserv and Knowledge Base. Sign up today!


CMS RELEASES FLURRY OF PAYMENT RULES
In addition to the recently released final 2019 Medicare Physician Fee Schedule rule, outlined in the above article, CMS recently released a number of annual payment regulations including the 2019 Outpatient Prospective Payment System (OPPS), Ambulatory Surgical Center (ASC), Home Health and updates to Medicare Advantage and Medicare prescription drug benefit (Part D) rules. These regulations include a number of payment policies changes for 2019, outlined in the CMS fact sheets provided below:

  • OPPS and Ambulatory Surgical Center rule
  • Home Health Agencies and Home Infusion Suppliers rule
  • Updates to Medicare Advantage and Medicare Part D rule 

CMS ISSUES REVISED ACO-11 PERFORMANCE SCORES
CMS recently provided ACOs with a revised detailed report for performance on the quality measure ACO-11, Use of CEHRT. CMS made corrections due to a number of calculation errors such as:

  1. Corrections in the MIPS ECs/QPs associated with the ACO (QPP eligibility);
  2. Corrections in which associated MIPS ECs/QPs met the Advancing Care Information (ACI) Base Score (ACI reporting); and/or
  3. Corrections in which associated MIPS ECs/QPs met one or more exclusion criteria (ACI category exclusion or QPP exclusion).

These corrections come after NAACOS repeatedly urged CMS to clarify how such calculations and exclusions would be performed/applied to ACOs. These widespread issues also recently caused CMS to recalculate all 2017 MIPS performance scores. A revised supplemental file for ACO-11 will be accessible through the SSP ACO portal and will contain a list of National Provider Identifiers (NPIs) in the denominator and a flag for whether they are in the numerator as well as your ACO’s revised numerator count, denominator count, performance rate and ACO-11 mean performance rate. 


GEISINGER INITIATIVE FEATURED IN THE BETTER CARE PLAYBOOK
Institute for Accountable Care executive director, Rob Mechanic, recently discussed Geisinger’s Community Health Worker Program with NAACOS Board Member Tony Reed in an interview featured on the Better Care Playbook. The Geisinger initiative is designed to address social service gaps, such as inadequate housing of food scarcity for high-need individuals by connecting them to local agencies to ensure these patients get timely access to primary care and to combat social isolation. Geisinger now employs more than 35 community health workers across 41 counties in central Pennsylvania. ACOs are increasingly investing in community health worker (CHW) models as the benefit for patients and the potential to reduce unnecessary health spending become more evident. The Institute for Accountable Care is planning a new initiative to work with ACOs to improve care for high-need, high cost individuals with support from three national health foundations. The project will begin in early 2019 with CHW programs as one of two models to be tested. If you would like to learn more about participating in this project, please contact Teresa Litton ([email protected]).


ASPE REQUEST FOR INFORATION ON EFFECT OF SOCIOECONOMIC STATUS ON QUALITY MEASURES
The Assistant Secretary for Planning and Evaluation (ASPE) has been tasked with conducting a study evaluating the effect of individuals’ socioeconomic status (SES) on quality measures and measures of resource use under the Medicare program. The first component of the required work, a 2016 Report to Congress, focused on socioeconomic information currently available in Medicare data. This request for information is part of the second component, which expands the analyses by using non-Medicare datasets to quantify SES and will be completed no later than October 2019 as required by the authorizing legislation (the Improving Medicare Post-Acute Care Transformation Act of 2014). More information is available on the ASPE website. Following up on ASPE’s first Report to Congress, HHS is now interested specifically in how plans and providers serving Medicare beneficiaries:

  • Identify beneficiaries with social risk factors,
  • Address the needs of beneficiaries with social risk factors,
  • Evaluate how these approaches affect quality outcomes and the total cost of care, and
  • Disentangle beneficiaries’ social and medical risks and address each. 

More information is available on the ASPE website. The comment period closes on November 16, 2018. Please share your input with us by emailing [email protected]. 


CMS UPDATES BILLING REQUIREMENTS FOR NEXT GEN HOME VISITS
CMS is changing the billing codes that Next Generation Model ACOs must use to bill for the Post Discharge Home Visit Waiver starting April 1, 2019. The home visits are one of the optional waivers Next Gen ACOs must apply for and encourage high-value services and care management. Next Gen ACOs are allowed up to nine in-home visits for patients who have been discharged from an inpatient facility in the last 90 days if they don’t qualify for home health services under Medicare. Billing codes for post-discharge home visits are the 12 Healthcare Common Procedure Coding System (HCPCS) codes outlined in a recent MLN Matters notice. Payment rates are published in the annual Medicare Physician Fee Schedule.


EXTENDING 2018 CONTRACT REQUIREMENTS AND VOLUNTARY TERMINATION DEADLINES
CMS has recently provided ACOs with additional details regarding agreement periods ending on December 31, 2018. As a result of the finalized policy in the Medicare Physician Fee Schedule rule, ACOs with an agreement period ending on December 31, 2018, will have the one-time option to voluntarily elect to extend their current agreement period in the Shared Savings Program for an additional six-month performance year, which begins January 1, 2019, and ends on June 30, 2019. 

ACOs must log into the ACO-MS and complete the ACO Extension tasks beginning no later than November 13, 2018, at 12:00 pm (noon) ET. ACOs must indicate if they are electing the voluntary six-month extension or voluntarily terminating their participation in the program on December 31, 2018. According to CMS, ACOs that elect to voluntarily extend must:

  1. Select “Yes” in ACO-MS for the ACO Extension task(s) to indicate that they will extend their Participation Agreement.
  2. Update the terms of the ACO Participant and Skilled Nursing Facility (SNF) Affiliate Agreements, as applicable, before the beginning of the next performance year to reflect the extension; and certify that the ACO has notified its ACO participants and SNF affiliates, as applicable, of their continuation in the program in 2019 and that the ACO Participant and SNF Affiliate Agreements have been updated. However, ACOs do not need to submit updated ACO Participant or SNF Affiliate Agreements to CMS for review to reflect the extension.
  3. ACOs participating in a performance-based risk track also need to update the terms of their repayment mechanism to reflect the extension. ACOs should submit their draft updated repayment mechanism documentation to CMS via the Shared Savings Program mailbox. Upon conditional approval, ACOs should submit final repayment mechanism documentation to CMS via tracked mail by December 14, 2018.
  4. Complete Annual Certification beginning November 19, 2018, through December 6, 2018. 

ACOs that do not elect to voluntarily extend must:

  1. Select “No” in ACO-MS for the ACO Extension task(s) to indicate that they will not extend their Participation Agreement.
  2. ACOs that do not elect to extend their agreement period will end participation in the Shared Savings Program on December 31, 2018, and must complete close-out procedures by the deadline specified by CMS. These ACOs will need to monitor email for additional information regarding close-out procedures. 

CMS asks ACOs to email the Shared Savings Program mailbox with any questions and include your ACO ID, indicate either “Repayment Mechanism” or “Extension” in the email subject line, and copy your CMS coordinator. 


NEW PATHWAYS RESOURCE PAGE
NAACOS has been highly engaged in many areas in recent months working to advocate in response to CMS’s proposal to overhaul the MSSP. We recently compiled all of our work related to the proposed Pathways to Success rule from CMS into a single webpage. The page contains analysis, webinars, news and advocacy updates to help ACOs understand the possible changes and stay on top of what it means for them. A final regulation is expected in late 2018 or early 2019. 


MEMBER RESOURCE ON NEW OPIOID LAW
On October 24, 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6) was signed into law, providing the second major piece of legislation in recent years to address the opioid overdose epidemic. NAACOS is an active member of a broad coalition pushing for easier sharing of patients’ substance abuse treatment records, and while we are disappointed the change wasn’t included in the final bill, the coalition continues to urge Congress to pass another bill addressing the issue later this year. The SUPPORT Act still has several changes that affect the work of ACOs, and NAACOS provides highlights for the 250-page law in a new resource. Read the document here. 


NEXT BOOT CAMP: FEBRUARY 2019 ON DOWNSIDE RISK
Join your ACO colleagues for the next boot camp in our very popular and successful series designed to give ACOs the tools they need to succeed. Our February 2019 boot camp in Orlando will be a deep dive into risk-taking. As CMS encourages its ACOs to take on greater risk, this boot camp will show ACOs how to choose their appropriate amount of risk. This boot camp will also teach ACOs the operational and clinical tactics necessary to succeed with greater risk. Boot camp faculty will use case studies, labs, and small group exercises to create an interactive and highly educational format. While designed for current MSSP Track 1 ACOs, all ACOs are welcome and may benefit from a deeper understanding of risk-taking. Mark your calendar for February 11–12, and we hope to see you in Orlando! 


UPDATED GUIDELINES ON PALLIATIVE CARE NOW AVAILABLE
The National Consensus Project (NCP) has updated its Clinical Practice Guidelines for Palliative Care with the introduction of the 4th edition of the guidelines. The NCP Guidelines are intended to standardize the clinical practice of care for persons living with a serious illness and their families in order ensure universal access to quality palliative care. These guidelines were developed and approved by 16 leading national organizations with expertise in improving the quality of life of patients and their families during serious illness. More information on NCP is available here.


B-CAPA REPORTS – AVAILABLE NOW!
The latest Benchmarking Comparative and Performance Analysis (B-CAPA) Reports were released to members on November 1. The B-CAPA Reports are ACO-level reports provided to NAACOS members that are included in the MSSP 2017 Performance Year. The B-CAPA Report evaluates spending, utilization, and quality for each MSSP ACO’s performance relative to comparable peer groups of ACOs. The reports also include data visualization and graphs prepared for each ACO. If the MSSP ACO had results in previous performance years, then past B-CAPA reports will also be uploaded into the member portal.  Questions? Contact Teresa Litton at [email protected].  To learn more about the B-CAPA Report, including a technical overview and how two ACOs use the reports, please join us November 13, 2018, at 2:00 pm ET.Free for members.Register here.


HIGH-LOW REVENUE ANALYSIS – EXPECTED SOON!
The High-Low Revenue Analysis looks at the impact of a notable provision in the MSSP proposed Pathways to Success rule and how each MSSP ACO would be categorized under this proposal. This is a new ACO-level report to support MSSP ACOs in better understanding how the proposed changes may affect them. More information will be provided along with the release of this new member resource.


ACOS: PATIENT STORIES NEEDED
More information about the positive impact ACOs are having in patients’ lives is needed. We hear touching stories at conferences and committee meetings, but now we want to share those patient success stories more broadly. If you or someone on your staff has a patient story that you can share or a patient able to be interviewed, please let us know! Contact [email protected]. 


NEW INSTITUTE FOR ACCOUNTABLE CARE WEBINAR!
The Institute for Accountable Care will be hosting an informational webinar on November 20, 2018, at 2:00 pm ET on the Demonstration for Improving Care for High-Need, High-Cost Individuals planned to begin in early 2019. The webinar will provide a summary of the project as well as ample time to answer questions. If you’re an ACO and interested in possibly participating in the demonstration, then please join us on November 20! Register here. Questions contact [email protected].


MEDPAC TALKS CHANGING ADVANCED APM BONUS
At a November meeting, the Medicare Payment Advisory Commission (MedPAC) discussed alternatives for encouraging advanced alternative payment model (Advanced APM) participation. Currently, Medicare pays a 5 percent bonus on clinicians’ fee-for-service (FFS) revenue for those that participate in an Advanced APM and also have a certain proportion of payments made “through” the APM, or they could meet this requirement based on patient counts through the APM. These thresholds are referred to as the Qualifying APM Participant (QP) thresholds, and only Advanced APM participants who meet the QP threshold receive the 5 percent bonus. As detailed in NAACOS’ ACO Guide to MACRA, the QP thresholds rise over time, and NAACOS has expressed concern with the all-or-nothing cutoff and increasing thresholds to qualify for the bonus. MedPAC discussed creating an incentive payment that’s proportional to the share of FFS revenue coming through an Advanced APM, which would eliminate current thresholds and encourage more participation in Advanced APMs. Changes to the bonuses, which end after the 2022 performance year corresponding to the 2024 payment year, must be approved through legislation by Congress. MedPAC plans to further discuss the possible policy recommendation later this year, and NAACOS will be monitoring that work as it moves forward. 


NAACOS WRITES HHS ON ANTI-KICKBACK CHANGES
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) should take further action to provide clarity and stability to MSSP waivers, NAACOS told the office in response to a request for information. NAACOS also urges the OIG to make permanent the safe harbors it provides MSSP from current anti-kickback requirements. Possible, inadvertent technical violations should also be avoided as the OIG works with other agency to update MSSP waivers. Furthermore, NAACOS recommends that ACOs should be allowed to cover patient cost-sharing as an incentive for wellness and managing chronic diseases. Read the full comment letter here. 


MARK YOUR CALENDAR: SPRING CONFERENCE ON APRIL 24–26 IN BALTIMORE
Mark your calendar for the NAACOS Spring 2019 Conference on April 24–26 at the Hilton Baltimore. Registration is now open! And if you missed the recent fall conference, you may purchase the recordings to access presentations by ACO experts and CMS officials.