Medicare Shared Savings Program

Question 1

Definition of ACO (4)

Answer 1

1. ) New category of health care providers created by ACA as part of Medicare Shared Savings program
2. ) Definition - a legal entity composed of certified medicare providers or suppliers. These providers and suppliers work together to coordinate care for a defined population of Medicare FFS beneficiaries, and they have control over the ACO’s decision-making process.
3. ) ACOs that meet specified quality performance standards are eligible to receive payments for shared savings if they can reduce spending growth below target amounts.
4. ) Medicare beneficiaries will be assigned to ACOs based on where they received certain primary care and preventive services in most recent 12 months.

Question 2

Eligibility requirements for ACOs to participate in the Medicare Shared Savings Program (7)

Answer 2

1. ) Must be eligible type of provider
2. ) Must be capable of receiving and distributing shared savings, repaying share losses, ensuring all providers comply with program requirements, and performing other required functions
3. ) Governing body must be at least be 75% of participating provider and include medicare beneficiaries served by the ACA
4. ) Leadership and management critiera include: clinical oversight done by senior level medical director who is a board-certified physician and providers must make meaningful financial or human investment to the clinical integration program
5. ) Must exhibit strong patient-centeredness element
6. ) Must have at least 5,000 beneficiaries and sufficient PCPs
7. ) Must have a compliance plan, lead compliance official, and mechanisms for identifying compliance problems

Question 3

Providers eligible to participate in an ACO (7)

Answer 3

1. ) Prof in group practice arrangements
2. ) Networks of individual practices
3. ) joint venture arrangement between hospitals and professionals
4. ) Hospitals employing professionals
5. ) Critical access hospitals that are paid by medicare in a way that supports collection of data needed to assign patients to providers
6. ) Rural health clinics
7. ) Federally qualified health clinics

Question 4

Ways ACOs must demonstrate patient-centeredness (8)

Answer 4

1. ) A beneficiary care experience survey
2. ) Patient involvement in ACO governance by representation in the governing body
3. ) Process for evaluating the health needs of the population
4. ) System in place to identify high-risk individuals and develop individualized care plans for targeted populations
5. ) Mechanism in place for coordination of care
6. ) Process in place for communicating clinical knowledge to beneficiaries in an understandable way
7. ) Process to allow beneficiaries to access their medical records
8. ) Processes for measuring clinical or service performance and using these results to improve care and service

Question 5

Quality Performance Core Domains (4)

Answer 5

1. ) Patient Experience
2. ) Care coordination and patient safety
3. ) Preventive care
4. ) Caring for at risk population

Question 6

ACO Beneficiary Assignment (2)

Answer 6

1. ) Beneficiary assigned to ACO if physician in that ACO account for the largest total Medicare allowable charges that beneficiary’s primary and preventive services for most recent 12 months.
2. ) CMS will review the claims for the remaining unassigned beneficiaries who had at least 1 primary or preventive services by a provider in ACO.

Question 7

Data sources for performance measures (3)

Answer 7

1. ) Survey instruments
2. ) Claims (supplied by CMS)
3. ) Electronic health record incentive program data

Question 8

Public reporting requirements of ACOs (2)

Answer 8

1. ) Organizational information (I.e list of all participants and members of the governing body)
2. ) Quality performance scores and shared savings or losses

Question 9

Benchmark Calculation (5)

Answer 9

1. )Based on prior 3 years of ACO baseline costs. Benchmark cost is weighted average of prior 3 years: yr 3 =60%, yr 2 = 30%, yr 1 = 10%.
2. ) Costs are risk adjusted for changes in health status.
3. ) Separate benchmark expenditures for certain beneficiaries.
4. ) Benchmark based on baseline only calculated at beginning of contract. The other years are trended.
5. ) Benchmark trended by Medicare part a and b trends a. Theses are risk adjusted.

Question 10

Payment Model Approach (2)

Answer 10

1. ) 1 sided model; but only can do once

2. ) 2 sided model

Question 11

Minimum Savings Rate (MSR) (2)

Answer 11

1. ) For 1-sided model, this is based in number of assigned beneficiaries. Once number of beneficiaries hit over 6,100, then this is 2%. Min is 500 with MSR =3.9%.
2. ) For 2 sided model, flat 2%

Question 12

Shared savings and losses percentages (2)

Answer 12

1. ) For 1-sided model, shared savings is 50%

2. ) For 2-sided model, gain is 60%. Losses is the min of 60% and (1-60% with quality score).

Question 13

Caps on gains and payouts

Answer 13

1. ) For 1 sided model, cap is 10% of benchmark cost.
2. ) For 2 sided model, gain cap is 15% of benchmark cost. Payout cap as percent of benchmark cost: yr 1 = 5%, yr 2 = 7.5%, yr 3 = 10%.

Question 14

CMS monitors ACO impact on at risk beneficiary (2)

Answer 14

1. ) CMS relies on beneficiary complaints, site visits, audits
2. ) data audited includes utilizations and cost data, quality performance measures, and shared savings distributions

Question 15

CMS actions if ACO is not in compliance (3)

Answer 15

1. ) Issues warning
2. ) Placed ACO on corrective plan or special monitoring
3. ) Terminates ACO

Question 16

Considerations regarding MSSP (7)

Answer 16

1. ) improving quality may not generate necessary savings
2. ) acos that target certain procedures may not achieve sufficient savings
3. ) few orgs willing to make necessary changes
4. ) risk analysis of util of services required to meet targets
5. ) may not have proper talent to successfully manage
6. ) ACO spending targets based on prior experience (more efficient providers have harder time to generate savings)
7. ) for efficient ACOs, have to focus on non-IP services to achieve savings

Question 17

Approaches and interventions for ACOs to optimize care and achieve performance targets (5)

Answer 17

1. ) Care redesign to improve the delivery and coordination of care (set up PCMH, improve hospital transitions)
2. ) Care management of patients with costly, complex needs
3. ) Patient and family engagement and patient activation initiatives
4. ) Integrated data and analytics
5. ) Supportive payment models and financial incentives