ACOs: Federal and State Update .


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ACOs: Government and State Upgrade. Danielle Drayer and Cara Zucker April 14, 2011. Layout. Review CMS' NPRM for Medicare SSP New York State's ACO Exhibit Program Government Law versus State Law. Diagram. Brief Timetable.
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ACOs: Federal and State Update Danielle Drayer & Cara Zucker April 14, 2011

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Outline Overview CMS\' NPRM for Medicare SSP New York State\'s ACO Demonstration Program Federal Law versus State Law

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OVERVIEW

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Brief Timeline March 23, 2010 - Section 3022 of the Patient Protection and Affordable Care Act (ACA) approved the making of a Medicare Shared Savings Program (SSP) for ACOs December 6, 2010 - New Jersey presented ACO Demonstration Project enactment in both houses (S.2443/A.3636) March 30, 2011 - New York passed enactment (Art. 29-E PHL) as a component of the financial backing to make an ACO Demonstration Program April 7, 2011 - CMS distributed a Notice of Proposed Rulemaking (NPRM) for the SSP April 7, 2011 - CMS and OIG distributed a NPRM on waiver outline regarding the SSP April 7, 2011 - FTC and DOJ issued a Proposed Statement on Antitrust Enforcement Policy identified with the SSP January 1, 2012 - The SSP is planned to start

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Program Estimates for the First Three Years Start up venture and first year working consumptions for ACOs is ~$1,755,251 Between 75 and 150 ACOs will take an interest Between 1.5 and 4 million Medicare expense for-administration recipients will be allocated Amount of shared reserve funds ranges from $560 million - $1,130 million Amount of punishments that may surveyed ranges from $10 - $80 million

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CMS\' NPRM for the SsP

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Eligibility Who can partake in the SSP? Amass hones Networks of individual doctor hones Joint ventures amongst doctor\'s facilities and doctors Hospitals utilizing doctors CAHs, FQHCs, and RHCs

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Agreement Period Three year assention period for starting companion (1/1/12 – 12/31/15) ACOs would be liable to new program gauges built up amid the understanding Exceptions: qualification necessities, count of shared reserve funds, & recipient task ACOs may not include members ACOs may subtract members or include/subtract suppliers ACOs required to tell CMS of critical auxiliary changes

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Legal Structure & Governance Legal structure must permit ACO to: get and appropriate shared reserve funds reimburse shared misfortunes build up, report, and guarantee consistence with program prerequisites Governing body must be contained: no less than 75% ACO members no less than one influenced Medicare FFS recipient discretionary: group partner association

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Program Integrity Requirements Must have a consistence arrange and an irreconcilable circumstances strategy All assentions between or among an ACO and its members and suppliers must require consistence with the ACO\'s support concurrence with CMS

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Leadership & Management Operations oversaw by an official under control of the representing body Clinical oversight gave by senior level restorative chief Physician coordinated quality affirmation and process change board of trustees Information innovation to gather and assess information and give input to suppliers Optional: elective structures won\'t be naturally denied

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Beneficiary Assignment ACOs must have an adequate number of essential care suppliers to serve no less than 5,000 Medicare FFS recipients Beneficiaries will be relegated reflectively in light of the majority of essential care administrations they get from taking an interest doctors

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Beneficiary Notification ACOs must post signs in offices that they are taking an interest in the SSP Standardized data must be given to all Medicare FFS recipients about SSP ACOs must illuminate recipients of capacity to demand claims information and the recipients\' entitlement to quit information sharing ACOs must advise recipients of their entitlement to get to administrations outside the ACO

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Patient Centeredness Beneficiary access to wellbeing records Patient contribution in ACO administration Evaluate wellbeing needs of the doled out populace, figuring in differing qualities Identify high hazard people and create individualized nurture focused on populaces Mechanism for care coordination and electronic trade of data for patient moves Communicate clinical learning/confirm based prescription to recipients Use CG-CAHPS overview to gather and cover recipients\' involvement of care Measure clinical administrations performed by doctors crosswise over practices

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Quality Measures 65 quality measures traversing 5 spaces: Patient/parental figure encounter Care coordination Patient security Preventive wellbeing At-hazard populace/slight elderly wellbeing

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Quality Reporting Requirements Performance scores will be ascertained utilizing claims information, GPRO, and studies

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Public Reporting Requirements Name and area Primary contact Organizational data, including ACO members Shared reserve funds data Performance installments or shared misfortunes Where investment funds are contributed Quality execution scores

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Data Sharing Limited recipient identifiable information will be made accessible upon demand: Name, DOB, sex, Health Insurance Claim Number Data utilize understanding required to get Medicare Parts A, B, & D claims information No sharing of liquor or substance manhandle records without patient assent Patients may quit information sharing Aggregate information gives an account of budgetary and quality execution

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Expenditure Benchmark Estimated for each ACO in view of Parts An and B FFS uses Updated every year amid the understanding IME and DSH installments might be expelled to conform the benchmark Geographic variety may not be considered while modifying the benchmark

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Track 1 versus Track 2

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Track 1 Shared investment funds would be accommodated every year for the initial two years utilizing an uneven shared reserve funds approach The ACO would not be considered in charge of misfortunes Resembles gainsharing Y3 ACOs on Track 1 would consequently be moved to Track 2 and put at hazard for misfortunes

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Track 2 Eligible for a higher investment funds rate Must set up a technique for reimbursing misfortunes 25% withhold would be connected every year to any earned execution installment Minimum misfortune rate of 2% connected for registering shared misfortunes

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Minimum Savings Rate ACOs can just share investment funds in the event that they surpass MSR Track 1 ACOs with under 10,000 recipients are absolved from MSR if: Only gathering hone courses of action as well as systems of individual practices take an interest; or ≥75% of recipients dwell in rustic regions; or ≥50% of recipients are doled out in light of getting to administrations from a CAH; or ≥50% of recipients had no less than one experience with a partaking FQHC or RHC

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Distribution of Shared Savings Six month claims run out would be utilized to compute benchmark and per capita consumptions CMS would inform each ACO of any common funds or shared misfortunes and the sum owed or due ACO must document composed demand to get shared funds ACO must pay CMS any misfortunes owed inside 30 days of notice

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Monitoring and Termination CMS may end understanding for cause Prior to ending an assention: Warning notification Corrective activity arrange Special observing arrangement ACO can pull back from program with 60 days see ACO is required to advise members and suppliers of end; recipients should likewise be told

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Future Participation Terminated ACOs may not rejoin until the start of another assention period ACOs that rejoin may just do as such on Track 2 If end was for cause, ACO must determine shields that have been set up ACOs that have encountered a net misfortune may not reapply

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Waivers and Antitrust Waivers To guarantee shared funds can be disseminated CMS has proposed waivers of specific arrangements of the doctor self-referral law, hostile to kickback statute, and common fiscal punishments Antitrust Review Proposed Statement applies to ACOs framed after March 23, 2010 and to coordinated efforts that collaborate with the Innovation Center Antitrust audit will be under run of reason examination Establishes wellbeing zones for ACOs that have ≤ 30% piece of the pie in a specific essential administration zone Optional survey = > 30% - ≤ half piece of the pie Mandatory audit = > half piece of the overall industry

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New York\'s aco exhibition program

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NY ACO Demonstration Program Article 29-E of PHL approves the Commissioner of Health to set up a show program to test ACOs as a conveyance framework Does not approve shared funds Seven endorsements of expert will be issued and none can be issued after December 31, 2015 The Commissioner may confine, suspend, or end an ACO\'s testament in the event that it neglects to work as per the law

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The Commissioner\'s Regulatory Authority

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NY ACO Demonstration Program Interested ACOs must: have an instrument for shared administration can arrange, get, and disperse installments consent to be responsible for the quality, cost, and conveyance of human services to their patients The Commissioner may effectively direct ACOs to guarantee they are legitimately worked

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NY ACO Demonstration Program The Commissioner may approve outsider payers to take an interest ACOs that go into plans with outsider payers may set up option installment procedures ACOs are allowed to get, pool, and circulate installments to taking part suppliers All monetary game plans are liable to control

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NY ACO Demonstration Program The State may give state activity invulnerability under antitrust law to both payers and suppliers The Commissioner, through control, may set up safe harbors that excluded ACOs from statutes relating to corporate routine of drug, expense part, and doctor self-referral The Commissioner is additionally approved to look for government endorsements and waivers to get money related cooperation

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Federal law versus state law

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FEDERAL VS. STATE

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