33 West Monroe St, Suite 1700 Chicago, IL 60603-5616 Tel 312 664 4467 Fax 312 664 6143 www.himss.org February 19, 2014 Marilyn Tavenner Administrator Centers for Medicare and Medicaid Services US Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Dr. Patrick Conway Deputy Administrator for Innovation & Quality Chief Medical Officer Centers for Medicare and Medicaid Services US Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Dear Administrator Tavenner and Dr. Conway: On behalf of the Healthcare Information and Management Systems Society (HIMSS), we are pleased to provide written comments to the Center for Medicare and Medicaid Innovation (CMMI), in response to its Request for Information on the Evolution of ACO Initiatives at CMS. We look forward to the opportunity for continuing dialogue with CMS as these payment delivery reform efforts evolve. HIMSS is a cause-based, global enterprise producing health IT thought leadership, education, events, market research and media services around the world. Founded in 1961, HIMSS encompasses more than 58,000 individuals, of which more than two-thirds work in healthcare provider, governmental, and not-for-profit organizations across the globe, plus over 600 corporations and 250 not-for-profit partner organizations, that share this cause. HIMSS strategy for formulating this response to CMS began with convening a targeted workgroup of HIMSS members with expertise in payment and reimbursement issues, specifically how these issues relate to the health information technology arena. Since the RFI contained specific questions and discussion items that fell both within and out of HIMSS scope, the workgroup identified relevant points to provide impactful feedback. SECTION I: Additional Applicants to the Pioneer ACO Model and Feedback on Current Model Design Parameters CMS Questions: Would additional health care organizations be interested in applying to the Pioneer ACO Model? Why or why not?
If additional applicants were solicited for the Pioneer ACO model, should CMS limit the number of selected organizations or accept all organizations that meet the qualifying criteria? What are the advantages and/or disadvantages of either approach? Other than the options for refining population-based payments outlined in Section B below, should any additional refinements be made to the Pioneer ACO Model that would increase the number of applicants to the Pioneer ACO model? HIMSS strongly supports the development and use of IT that will provide healthcare information required by emerging care delivery and business models and payment structures, such as Accountable Care Organizations (ACOs), to effectively manage and treat patients across the continuum of care including outpatient, inpatient, ancillary, emergency and post- acute care settings. 1 Anecdotal feedback suggests that the Pioneer ACO model has been modestly effective and cost-beneficial. Many throughout the health IT ecosystem can and will rely on the evolution of new business models fostered by pioneer ACOs and other delivery system reform efforts to refine the use of health IT to support improvements in care delivery. Therefore, these evolving models play a key role in IT s evolution as well, by helping to encourage the adoption of interoperability standards and enhance design and usability of health IT tools in order to meet provider, patient and caregiver workflow needs. We believe that increasing opportunities for applicants for the next generation of Pioneer ACO models can help to further enhance the impact of the technology that underlies and enables these reforms. We support continued experimentation with payment models that will generate appropriate incentives and reward the most efficacious and cost-effective approach to treatment, given an individual s unique health and financial situation. We encourage CMS to be open to the participation of a variety of care organizations, as the more diverse the organizations that participate, the greater the learning that will occur. For example, providers servicing different populations or similar populations with different geographic challenges may develop different strategies for meeting the same requirements. The greater the variety of approaches employed by program participants, the greater the possibility of identifying best practices for specific situations. We note it is important to acknowledge the challenges inherent in the current population-based payment model that act as deterrents to participation. Many current and previous participants in the CMS Pioneer ACO Program have cited difficulties in tracking the progress and health status of patients who have the option of receiving care outside of the ACO without notifying the ACO. o In situations where the patient notifies the ACO they are planning to, or have received care outside of the ACO, the absence of a fully functioning health information exchange impedes the ACO provider s ability to maintain a comprehensive picture of the care the individual is receiving or to track the individual s progress or regression on specific measures. 1 HIMSS 2013-2014 Public Policy Principles: http://himss.files.cms-plus.com/filedownloads/himss-public- Policy-Principles-2013-2014.pdf 2
Many health IT systems in place in a provider s office are still evolving; as a result, such settings currently lack the level of sophistication needed to track information at the level of detail required under the Pioneer ACO program. With many variables outside their control, organizations find that the risk associated with accepting responsibility for patient outcomes outweighs the potential rewards. To address these concerns, CMS could consider implementing patient incentives that would encourage individuals to receive routine care within their assigned ACO, coordinate specialty care received outside the ACO with their ACO Primary Care Physician, and request that any practitioner who treats the individual provide a copy of the clinical records for that visit or episode of treatment to the individual s assigned ACO. For our part, the health IT community will continue to work toward interoperability that leads to the information exchange ACOs will need to be successful. Population-Based Payments (PBP): HIMSS offers observations on two CMS questions that are within scope of our expertise. Would being able to choose different FFS reduction amounts for Part A and Part B services be of significant import when deciding to participate in the PBP? Why or why not? Having a choice could enable the applicant to see benefits in concurrent programs i.e., the EHR Incentive Program and payer-specific performance-based programs to reduce risk of failure. We acknowledge that different markets support flexibility in payment models, and differentiating Part A and Part B Fee for Service (FFS) reduction amounts could allow flexibility in the technology deployed to achieve the Triple Aim of ACOs reducing costs, improving patient experience, and improving health outcomes. An important consideration for some, however, will be whether or not the reduction amounts take into consideration the medical severity of the population being served. It is critical to the success of the program that those entities whose level of expertise or geographic location attracts a more acute case load are not adversely affected for becoming centers of excellence or meeting critical community needs. Should CMS reconsider the requirement that a Pioneer ACO generate a specified level of savings in previous years in order to be eligible to elect to receive PBPs, and instead establish clear requirements for financial reserves? Why or why not? Actuarial capabilities of technology are becoming more sophisticated, allowing us to determine the financial risk and impact of specific patients and populations of patients. We caution that, by requiring specified levels of savings in prior years for eligibility, CMS might inadvertently encourage uses of technology to manage populations against an ACO specific internal benchmark, which could lead to detrimental impacts on specific patients. CMS could consider using aggregated data to develop a severity-adjusted benchmarking scale that links cost data to episodes, and allows ACOs to compare their populations to that scale. Should any additional refinements be made to the current Pioneer ACO PBP policy? 3
One way CMS could help ensure the success of these programs is to refine the current PBP policy to provide timely analytics and forecasting data. These forecast models and readjustments could be based on longitudinal data analytics that can project medical loss ratios on a routine basis. Technology is available for Medicare Shared Savings Program (MSSP) ACOs to utilize real-time eligibility information. For next generation ACOs to succeed, it is vital that the Pioneer ACO policy be modified to support real-time eligibility data and real-time identification of the beneficiaries who comprise the ACO panel, as well as much more timely delivery of claims data. This is necessary not only for proper functioning of the complex analytic models, but also for ACOs to guide and support their providers in utilizing the patient-centered, coordinated care that is the key to improving outcomes and lowering costs. Our members experiences with existing pioneer ACOs suggest that refinements may be needed on current minimal savings rates that must be demonstrated to be eligible for PBP. This mitigates some of the model adoption hesitation by potential applicants because of the significant investment in time, resources, and IT. Additionally, there is concern with the sustainability of the current CMS ACO model. There is opportunity for clinical workflow efficiency and quality outcomes improvement with the coordinated and proactive treatment of chronic conditions, particularly diabetes or heart disease, however concerns remain regarding what return on investment will look like. There is also concern about potential downstream impacts for IT, should these savings not be demonstrated cuts for staff, including IT, as a byproduct of these ramifications. We note that IT staff is critical for data generation for existing Pioneer ACOs. These ACOs with innovative and viable business models should research best practices in IT solutions that will be key to ACO success for demonstrating quality outcomes. These best practice technology solutions for this type of reporting will be instrumental to the success of ACOs, as well as mitigating the potential IT staffing loss risk associated with not meeting the targeted required savings objectives. Finally, larger healthcare institutions could find it difficult to identify which patients are to be managed under the ACO. This differentiation of status may cause a difference of care protocols for different populations at large institutions. Section II: Evolution of the ACO Model CMS is seeking input on models that (1) transition ACOs to full insurance risk, (2) hold ACOs accountable for total Medicare expenditures (Parts A, B, and D), (3) integrate accountability for Medicaid outcomes, and/or (4) offer ACOs payment arrangements with multiple accountability components (such as shared savings/losses, episode-based payments, and/or care management fees). CMS recognizes that these strategies are not necessarily mutually exclusive, such that a new initiative could incorporate several of these strategies. CMS also believes that the adoption of the ACO model by private payers offers an opportunity to strengthen the incentives in the model while reducing burdens on providers and is interested in opportunities to advance that alignment. Transition to greater insurance risk: 4
While the questions in this section do not fall neatly within the HIMSS scope, we offer the following observations on program issues specifically centered around two questions posed by CMS: What are potential program integrity issues that ACOs transitioning to full insurance risk may encounter and what are appropriate preventative safeguards? What types of precautions should be taken by ACOs assuming full insurance risk to protect beneficiaries from potential marketing abuses limiting beneficiary freedom of choice? What are additional protections beyond those in Medicare Advantage that would be important for beneficiaries aligned to ACOs with full insurance risk to avoid adverse selection? To ensure the greatest opportunity for success under a shared risk model, it is important that risk be appropriately distributed between the ACO and its payers, with ACOs bearing enough risk to encourage effective management of their population of patients without putting them in peril of being unable to maintain their business. We note it is also important that any risk model allow for the severity of an individual ACO s population and demographic or geographic attributes and that the ACO have appropriate financial reserves in place to protect it against the risk it is assuming. Finally, CMS should be thoughtful about state regulations regarding the assignment of risk between carriers and providers and work to ensure that any approach avoid being negatively impacted by state requirements. CMS asks what are approaches for setting appropriate capitation rates? The Pioneer ACO program currently uses a national expenditure growth trend for benchmarking. What are the advantages and disadvantages of using national expenditure growth trends? What about for using a local reference expenditure growth trend instead? Creating a locally-based trend analysis for ACOs to determine capitation rates could be beneficial, as well as a comparative analysis component between local and national benchmarks. It would also be beneficial to compare with HIE entities. HIMSS encourages CMS to utilize analytics to support progress of ACOs and promote effective and accurate coordination of benefits between payers, durable medical equipment (DME), and pharmacy marketing quality controls. These efforts can also aid in identifying fraud and abuse. Finally, CMS asks what are the advantages or disadvantages of different strategies for riskadjustment? (Examples include demographic risk adjustment only and/or any of the Medicare Advantage risk adjustment methodologies.) An effective strategy for risk adjustment should consider environmental, demographic and socioeconomic factors affecting the population which a particular ACO serves, and a standardized approach allowing for the variances in population among different ACOs. One of the challenges with the current MSSP ACO risk-adjustment methodology is that it is perceived as preventing modifications to the individual patient Risk Adjustment Factor (RAF) scores as long as the patient is continuously assigned to the ACO. Replacing the RAF component of the current MSSP 5
ACO risk-adjustment methodology with a more flexible risk-adjustment strategy would create an environment where incentives for ACOs could be more effectively aligned with treatment protocols. Integrating accountability for Medicare Part D Expenditures: In the RFI, CMS notes that an approach for increasing Medicare accountability is for ACOs to integrate Part D expenditures as part of their approach to care delivery and health care transformation. While not all of the questions in this section fall within the HIMSS scope, we offer the following observations on the following question raised by CMS on the topic of ACO data. Do ACOs currently have access to enough data to accept full risk for Part D expenditures? What other mechanisms would allow ACOs to assume accountability for Part D outcomes? In general, ACOs are not perceived to have timely data, or even the volume necessary to accept full risk for Part D expenditures. While CMS provides claims data, the challenge is that this data may not be timely or comprehensive enough for a risk determination for this, clinical data is needed. More clarity is needed on what the risks are and what the potential to manage the risk is. Capturing both structured and unstructured data elements in clinical records should also be considered. Currently, there is no requirement of transmission or reception of prescription drug data between pharmacy and provider systems; if ACOs are to assume full risk for Part D expenditures, CMS should consider this point. We recognize that many care coordination efforts utilize Part D spend as an offset to reduce other categories of spend, and as such, accepting risk for Part D requires that the ACO be fully functioning on all other spend categories, or aggregate spending could increase. Therefore, the use of technology to coordinate the beneficiaries care across the continuum will require improved timeliness and completeness of the data for all categories of spend provided by CMS. An example will be real-time eligibility transactions in addition to Part A and B claims which must arrive much faster to support Part D risk-taking by the ACOs. Integrating accountability for Medicaid Care Outcomes: As CMS seeks input on approaches for ACOs to assume increasing accountability for Medicaid outcomes, HIMSS offers the following observations on the questions posed. CMS has encouraged States to explore the use of integrated care models including ACOs for the care of Medicaid populations. Should ACOs caring for Medicare outcomes also assume accountability for Medicaid outcomes? What populations should CMS prioritize in integrating accountability for Medicaid outcomes? For instance, should ACOs be accountable for outcomes among all Medicare- Medicaid beneficiaries treated by the ACO historically? Or, should the ACO be accountable only for those Medicare-Medicaid beneficiaries over 65 years old or under 65? Alternatively, should the ACO be accountable for outcomes of all Medicaid 6
beneficiaries as well as CHIP beneficiaries? Should they be accountable for all those beneficiaries residing in a specified geographic area, regardless of whether they had been cared for by the ACO? The technology and tools necessary to effectively manage Medicare populations are transferable to the Medicaid population, and therefore on a voluntary basis, many of the ACOs are preparing to assist with Medicaid populations. Without a Medicaid managed care model, many patients move in and out of Medicaid eligibility over the course of a year. As such, the care of these patients is frequently fragmented, distributed across multiple ambulatory and hospital records and with disparate medical record identifiers. This makes it challenging to incorporate and manage in an ACO care delivery model. On the other hand, enrollment in a managed care plan requiring a primary care provider should result in better care coordination with less emergency department utilization. Administrative information available from such a setting might then be significantly more coherent, thereby encouraging the assumption of risk. An enrollment model without requirement for a care manager, while helpful, would likely be inadequate to assure the data coherence necessary to encourage risk assumption. Such managed Medicaid models exist (e.g., Louisiana) and appear to result in improved care at lower costs. This care management system should include clear incentives that motivate the beneficiary to accept the care and recommendations of his ACO provider team, which is key for the success of both Medicare and Medicaid ACO programs in the long term. What are the current capabilities of ACOs and other providers in integrating and using Medicare FFS and Medicaid FFS data to drive care improvement and performance reporting? What are the capabilities of providers in integrating this data with electronic health records? What are the capabilities of integrating information for care received in the community or from other non-traditional care providers? Use existing IT capabilities where these capabilities are fully functioning. That being said, we acknowledge that these can be challenging to obtain. We also note that integrating information from ancillary care sources, such as clinics, nursing homes, etc. could be difficult as these systems are disparate and syncing the data could prove difficult. A data clearinghouse could be a viable option. Multi-Payer ACOs: CMS has required that Pioneer ACOs demonstrate experience with riskbased contracts as a pre-condition for assuming such contracts with CMS as well as to encourage multi-payer alignment of incentives. CMS is seeking input on how best to promote multi-payer alignment of payment incentives and quality measurement. How can CMS and other payers focus reporting of quality measures on the most important priorities while minimizing duplication and excess burden? The single most valuable contribution that CMS can offer in this area is to develop national uniform quality metrics, and apply them across the full continuum of care. CMS should continue its thought leadership on efforts to create uniform quality metrics and work with HIMSS and the 7
health IT community to facilitate efforts to establish a clearinghouse of quality measures for multi-payer ACO arrangements. HIMSS appreciates the opportunity to comment on this RFI, and we look forward to offering our members voices on IT issues, opportunities, and challenges surrounding payment delivery reform efforts. For more information, please contact Thomas M. Leary, Vice President of Government Relations, 703.562.8814 or Stephanie Jamison, Director of Government Services, 703.562.8844. Sincerely, Scott T. MacLean, MBA, CPHIMS, FHIMSS Chair, HIMSS Board of Directors Deputy CIO, Director of IS Operations Partners HealthCare in Boston, MA H. Stephen Lieber, CAE President/CEO HIMSS 8