Posts Tagged ACO
By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS
The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.
Incentives: The Good, the Bad, and the Ugly
The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.
An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.
The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).
The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.
Subtle Changes to Traditional Reporting
The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).
The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.
Individual EP Reporting of Individual Measures
EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.
As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:
- Qualified direct electronic health record (EHR)
- Qualified EHR data submission vendor
Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.
Aligning Quality Initiatives
There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.
“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule
In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.
As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.
An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.
Individual EP Reporting of Measures Groups
EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).
There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:
- Diabetes Mellitus
- Chronic Kidney Disease
- Coronary Artery Bypass Graft (CABG)
- Preventive Care
- Rheumatoid Arthritis
- Perioperative Care
- Back Pain
- Coronary Artery Disease (CAD)
- Heart Failure
- Ischemic Vascular Disease (IVD)
- Hepatitis C
- Chronic Obstructive Pulmonary Disease (COPD)
- Sleep Apnea
- Irritable Bowel Disease (IBD)
- Cardiovascular Prevention
CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.
Group Practice Reporting
CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.
Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.
Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).
Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.
Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.
If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.
As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PhysicianReview-ICN904144.pdf).
There’s Still Time to Act
Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).
Avoiding the PQRS Negative Adjustment
CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.
If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.
CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:
- Satisfactorily report and earn the 2013 incentive of 0.5 percent.
- Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
- Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.
The Push for Better Care and Outcomes
CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”
Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.
April 1st, 2013
By Stephen C. Spain, MD, FAAFP, CPC and Angela “Annie” Boynton, BS, CPC, CPC-P, CPC-I, CPC-H, RHIT, CCS, CCS-P
Part 3: Securing the right care at the right time depends on whether ACOs can incorporate EBM into everyday practice.
Editor’s note: This is the final installment in a three-part series on health care quality, value, and the future of health care reimbursement in the United States. Our first article discussed the rise of evidence-based medicine (EBM); and last month we talked about accountable care organizations (ACOs) being the (r)evolutionary next step driving quality and value.
Medicare ACOs are intrinsically linked to performance measures, quality outcomes, and incentive-based reimbursement. The government is betting these links will improve health care outcomes and reduce costs. EBM can secure the right care at the right time: The key is whether ACOs can incorporate EBM into everyday practice.
Quality measures are a critical component of the ACO final rule. The formulation of a quality measure generally begins by identifying a problem, posing a possible solution, and following up with clinical evidence, as shown in the Table A. Supporting evidence in the form of clinical trials and studies, and deference to any existing EBM guidelines, allows the steward organization to create a measure that can be used for tracking or, in the case of ACOs, for incentive-based reimbursement.
Specifics of ACO Quality Measures
The ACO final rule stipulates reporting on 33 quality measures. These 33 individual measures will determine whether an ACO qualifies for shared savings. The measures are divided into two categories: Better Care for Individuals and Better Care for Populations. The quality measures are further divided to span four quality domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At Risk Population.
Patient/Caregiver Experience of care has an ultimate goal of measuring care for individuals. Using a survey mechanism for submission, this domain includes seven quality measures aimed at providing better care for individuals:
1. How well your doctors communicate
2. Getting timely care, appointments, and information
3. Patients’ rating of doctor
4. Access to specialists
5. Health promotion and education
6. Shared decision-making
7. Health status/functional status
The Care Coordination/Patient Safety domain continues to focus on better care for individuals, with six measures:
1. Risk-standardized, all condition readmission
2. Ambulatory sensitive conditions admissions: Chronic obstructive pulmonary disease (COPD)
3. Ambulatory sensitive conditions admissions: Congestive heart failure
4. Percent of primary care physicians who successfully qualify for an electronic health record (EHR) incentive program payment
5. Medication reconciliation: Reconciliation after discharge from an inpatient facility
6. Screening for fall risk
The Preventive Health domain shifts focus from individuals to better care for populations. Eight measures are included:
1. Influenza immunization
2. Pneumococcal vaccination
3. Adult weight screening and follow up
4. Tobacco use assessment and tobacco cessation intervention
5. Depression screening
6. Colorectal cancer screening
7. Mammography screening
8. Proportion of adults 18+ who had their blood pressure measured within the preceding two years
The remaining measures are categorized in the At Risk Population domain. The objective continues to be better care for populations with chronic illness. The measures are divided into clinically deemed, at-risk populations, including those suffering from diabetes, hypertension, ischemic vascular disease, heart failure, and coronary artery disease.
Measures Reporting and Payment
All measures ultimately are reported via the Internet. The Physician Quality Reporting System (PQRS) combines some of these existing measures into its reporting structure, so providers who participate in PQRS and are in an ACO do not face duplicate reporting requirements.
Payments are made based on the three-year commitment. The first year (2012), ACOs are paid to report. This enables the government to begin amassing data from existing, fledgling ACOs, which can be combined with existing Medicare claims data. These combined data allows the government to set benchmarks for quality and begin the scoring process.
Measures are phased in over years two and three of the initial ACO commitment. This avoids the stress and burden that would come from an all-at-once process, and allows ACOs to structure business operations over time and become more familiar with the measures.
ACOs = Opportunity for Coders
Understanding and addressing the central position of quality measures, PQRS, and ACOs will be crucial for all health care participants—including coders—in the years ahead. The obvious question for AAPC members is, “How will the evolving focus on EBM and quality measures reporting affect me?”
There are a few key points to consider:
- Quality measures are reported by codes, and AAPC membership owns the coding world. No one understands coding like our members, and no group is as well positioned to tackle the challenges associated with changes and requirements in health care coding. Coders must begin learning how to identify and use these new codes. Specialty coders must learn and identify the reportable measures pertinent to their field. The National Quality Forum website is a great resource for learning about the specific quality measures and their codes.
- Apart from providers, no one in health care has a better understanding of navigating the medical record than coders. Providers will have enough difficulty following necessary guidelines and documenting required measures. It will fall on “others” to access the health care record to identify, locate, tabulate, and report measures. In our view, those “others” will be largely the coding membership of AAPC, who will need to work with providers and EHR vendors to simplify entry into and extraction from the record for the required reporting elements. We foresee many coders will become experts in data extraction and reporting. Successful performance of these tasks will have significant financial implications for providers, imparting new responsibilities and heightened importance for coders.
- At the outpatient provider level, reporting measures is in its infancy. Providers are looking for well-informed and reliable sources to help them understand and participate in quality measures reporting. They are just beginning to realize the looming financial penalties for noncompliance; this will fuel their desire to understand the new initiatives. Proactive coders will be prepared to address this provider need by learning how to implement new reporting requirements. In doing so, the forward-thinking coder will be firmly planted as part of the foundation of this new direction in health care delivery. The CMS website is a good place to start learning about quality measure initiatives.
We are at the threshold of significant and far-reaching changes. Everyone participating in the delivery and reimbursement of medical care is hopeful that we are ushering in a “golden age.” With the proper preparation and education, AAPC members are poised to play a vital role in this new era. Regardless of the outcome of this experiment, AAPC membership and leadership must plan and work together, so it can never be said we were unprepared to meet the challenge.
Table A: Quality measures based on clinical evidence.
|Depression is a common illness for which there is effective intervention. Untreated, depression is associated with significant morbidity and loss of productivity.
||Would routine depression screening lead to increased rates of diagnosis and treatment, improving the quality of life for those patients identified with this condition?
||U.S. Preventive Services Task Force (USPSTF) evaluates the effect of primary care routine screening of adult patients for depression compared with usual care in 14 randomized trials in primary care settings.
||USPSTF concludes that, compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow up.
||The Centers for Medicare & Medicaid Services (CMS)
||NQF 0418: Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool and documented follow-up plan.
|Smoking is associated with significant illness and premature death.
||Can physician-directed screening and intervention reduce the rate of smoking in a patient population, thereby reducing overall smoking related morbidity and mortality?
||Multiple studies over many decades confirm that patients who are identified and counseled by health care workers to stop smoking are more likely to be successful in their cessation efforts.
||An American Medical Association (AMA) advisory group concludes that, while screening alone increases the rate at which clinicians intervene with their patients who smoke, it does not, by itself produce significantly higher rates of smoking cessation. Cessation interventions are also required to impact the outcome of interest.
||AMA Physician Consortium for Performance Improvement
||NQF 0028: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received tobacco cessation counseling intervention if identified as a tobacco user.
|Complications of influenza include pneumonia, heart attack, stroke, and death. These are associated with significant health care costs, not to mention the devastation to patients and families.
||Can we identify those at risk for influenza complications and reduce their risk of illness through vaccination?
||Multiple large studies over many decades have evaluated the effectiveness, cost, and safety of widespread vaccine administration for influenza and multiple other vaccinations.
||Centers for Disease Control and Prevention Advisory Committee for Immunization Practices concludes influenza vaccine administration lowers the risk of significant illness for patients over 50, and persons with underlying illnesses like asthma, COPD, and diabetes.
||National Committee for Quality Assurance
||NQF 0041: Percentage of adults aged 50 and over who received an influenza vaccine within the measurement period and within the respective age-stratified Consumer Assessment of Healthcare Providers and Systems surveys.
For more information on ACOs and the Shared Savings Program, read the CMS final rule in the Federal Register.
Stephan Spain, MD, FAAFP, CPC, has been engaged in the full-time practice of family medicine for 25+ years. He founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at firstname.lastname@example.org.
Annie Boynton, BS, CPC, CPC-P, CPC-I, CPC-H, RHIT, CCS, CCS-P, is the director of 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College and a developer and member of AAPC’s ICD-10 training team.
January 1st, 2013
There are several delivery systems that can evolve into accountable care organizations (ACO). If your practice is looking to take advantage of this new health delivery, cost saving, and revenue model, you ought to know what they are.
Before establishing or joining an ACO, evaluate your practice, its structure, and its affiliations. Look to similar models and study their experiences. One of these examples, compiled by Health Policy Brief, may fit your practice perfectly.
- Integrated delivery systems own hospitals, physician practices, and insurance plans. Highly organized, they boast sophisticated electronic health records, team-based care, and aligned financial incentives. Examples are Geisinger Health System, Pennsylvania; Group Health Cooperative, Seattle; and Kaiser Permanente, California.
- Multispecialty group practices enjoy a history of physician leadership and contract with a number of payers. Many, like Minnesota’s Mayo and Ohio’s Cleveland clinics, already have a history of physician leadership and coordinated clinical care.
- Physician-hospital organizations function a lot like the multi-specialty group practices, but may have nonemployee medical staff and remodel care delivery for cost effectiveness. Examples include Middlesex Hospital, Connecticut, and Advocate Health, Chicago.
- Independent practice associations actively redesign their practices and focus on quality improvement. They are made up of independent physician practices jointly contracting with payers. Massachusetts’ Atrius Health and California’s Monarch HealthCare two of the most successful in this care style.
- Virtual physician organizations are made up of small physician practices, often in rural areas. They may be led by physicians or state Medicaid agencies in a structure providing leadership, infrastructure, and resources to small practices coordinate care. ACOs develop within this model include those in Grand Junction, Colo.; Community Care of North Carolina; and North Dakota’s Cooperative Network.
December 19th, 2012
By Stephen C. Spain, MD, FAAFP, CPC
Angela “Annie” Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT
Part 2: As health care moves away from fee-for-service, quality care comes to the forefront.
Evidence-based medicine (EBM) and the Physician Quality Reporting System (PQRS) have brought the concept of pay for performance (P4P) to health care. The (r)evolutionary next step driving quality and value is the accountable care organization (ACO). The concept of accountable care begins where P4P ends: More than offering incentives for quality care, it requires quality care as a condition of reimbursement.
In October 2011, the U.S. Department of Health & Human Services (HHS) released a final rule governing the formation of ACOs. ACOs were implemented as a voluntary program in January 2012 as a result of the Affordable Care Act (ACA) and a modification to the Social Security Act (SSA), which established a funding source known as the Shared Savings Program. The ACO provisions represented only seven pages of the massive ACA; however, they were one of its most publicized provisions (along with the individual mandate).
Through the Shared Savings Program, the ACO initiative creates incentives for health care providers to work together to treat an individual patient across care settings, including physician offices, hospitals, and long-term care facilities.
Payers can form ACOs, and many have. UnitedHealthcare, Aetna, and Humana—each of which has vast experience with performance-driven care outcomes—have all formed ACOs. There are both commercial and Medicare ACOs. Many ACOs have been established by community-based programs and provider groups.
ACOs Require Performance Measure Reporting
ACOs seek to reduce health care costs, coordinate care, eliminate duplication of care, and prevent medical errors while ensuring better data integrity. ACOs meeting specific performance objectives over a three-year introductory period will share in any savings they create through lowered health care costs (versus estimated costs using a “traditional care” model). ACOs unable to meet the performance objectives will be penalized. The goal is to share in rewards and risk across all participants in the ACO.
Like PQRS and other quality monitoring programs, ACOs rely on data—much of which will be derived from patient charts by certified medical coders. The final rule adopts 33 individual measures of quality performance used to determine if an ACO qualifies for incentive shared savings. These performance measures span four quality domains:
- Patient Experience of Care
- Care Coordination/Patient Safety
- Preventive Health
- At-risk Populations
Reporting conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), vascular disease, risk for falls, diabetes, hypertension, tobacco cessation, depression, certain types of cancers, and immunizations all will depend on data provided by certified medical coders, and will help to determine if the ACO will share in savings or face penalties.
Moving Away from Fee-for-service
As a reimbursement methodology, ACOs are vastly different from traditional fee-for-service (FFS), which is the most common reimbursement methodology in the United States. In an FFS system, providers are paid based on the number of tests, treatments, surgeries, or studies they perform; hospitals are paid based on the number of beds they have occupied. The focus is on “how much” (quantity) care is provided, rather than “how good” (quality) the care is.
The concept of quality-based reimbursement (such as P4P) has existed for approximately 25 years, but has only begun to pick up steam in the past 10 years with the advent of the physician quality reimbursement initiative (now PQRS). If successful, the ACO model will revolutionize the way we receive, and pay for, health care in the United States.
ACO: HMO Take 2?
There are many differences between standard health maintenance organization (HMO) models and ACOs. When the Health Maintenance Organization Act of 1973 was passed and pioneered managed care, Americans were hesitant to allow Big Brother to oversee health care. It took nearly a decade for the managed care concept to catch on, but when it did, we learned that managing care saves money. There were, however, drawbacks in the way HMOs governed access to care. For example, HMOs are insurer driven and care can be fragmented; there is often little collaboration or cooperation in care delivery. There are gatekeepers—usually a provider that controls a patient’s access to higher levels of care (which raises the often worrisome in-network versus out-of-network dilemma)—and the overall focus of HMOs and managed care remains on quantity rather than quality.
Unlike the HMO or managed care model, the ACO model is provider driven. Care is intended to be fully integrated and should occur more collaboratively. Team-based care is a primary tenet of the ACO. There are no gatekeepers in ACOs, and the overall focus is on the quality and efficiency of care. Rather than being incentivized to deny expensive care, the ACO receives incentives for higher quality outcomes.
There are risks associated with the ACO model. Early participants in ACOs are not fully weaned from of the FFS system, so ACOs remain an unproven reimbursement system. We are not likely to see quality-based outcome measures or quality-based financial incentives for a year or more.
Another potential danger is ACOs will engage in “cherry picking,” or choosing only the healthiest patients to treat. The Centers for Medicare & Medicaid Services (CMS) has announced they will penalize any ACO caught cherry picking, and there are protections built into the final rule so cherry picking ACOs stand to lose money. Concerns remain that this may not be enough to combat the problem.
Perhaps the greatest risk is that there are no gatekeepers: There is nothing requiring a patient to remain with an ACO. In other words, if a patient wants to obtain health care from providers outside the ACO, he or she may do so using traditional Medicare insurance. The ACO would be penalized for these out-of-network expenditures (presumably, if the ACO’s quality of care and patient satisfaction are high enough, there would be no reason for a patient to seek health care elsewhere). This patient freedom represents a big gamble for fledgling ACOs.
The United States has yet to design a perfect health care system. If ACOs are to be successful, they must have a solid foundation with which to bridge the divide between FFS and accountable care.
Stephen Spain, MD, FAAFP, CPC, has been engaged in the full-time practice of family medicine for over 25 years. In 1998, he founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at email@example.com.
Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, is the director of 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College, and a developer and member of the AAPC’s ICD-10 training team. Ms. Boynton frequently speaks and writes about coding matters, including ICD-10 and 5010 implementation.
December 1st, 2012
With the Centers for Medicare & Medicaid Services (CMS) predicting the number of affordable care organizations (ACOs) will double to 300 by the end of 2012, it is time to start thinking about what you and your providers need to do to become Medicare ACO partners.
How does a Medicare ACO function and how will it potentially affect your office?
Born of the Affordable Care Act, Medicare ACOs are made up of a group of Medicare providers and suppliers. Under the ACO, the providers and suppliers agree to band together, coordinating care, documentation, and billing for patients, improving quality and cost savings in the process. Providers, payers, and newly established groups have applied to CMS for approval to start an ACO, which if approved must operate for at least three years.
An ACO’s quality performance is evaluated in five areas: care coordination, patient safety, preventive health, patient/caregiver experience, and at-risk population/frail elderly health.
CMS’ Medicare Shared Savings Program (MSSP) bases financial incentives to ACOs on successful cost reduction via care coordination. Under the MSSP, ACOs serve a minimum of 5,000 beneficiaries and must provide enough primary care physicians to easily serve the population. Before applying for MSSP status, an ACO must establish legal and governance structures, cooperative clinical and administrative systems and a shared savings distribution protocol.
Incentive payments are based on comparing an ACO’s annual incurred costs relative to CMS determined benchmarks and ACOs can choose to be reimbursed based on a “one sided” or “two sided” model. The one sided model allows the ACO to share a maximum of 50 percent for the first two years and savings or losses the third year. The two sided model allows a maximum of 60 percent sharing of savings and losses for all three years. Shared loss grows from 5 percent to 10 percent over the three year period.
A key to success is the communication of patient information, which adds a new perspective on current, interoperative electronic health record (EHR) systems. ACOs were ideated to encourage seamless treatment of patients by teams of providers from different entities and disciplines. Universally reliable documentation and classification of each patient may help providers meet incentives while providing improved quality of care.
If you are updating your EHR, investigate its ability to capture and communicate the information needed by other practices, physicians, and providers who may be joining your practice in a future ACO.
November 26th, 2012
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