AMGA Webinar: MSSP Final Rule. Scott Hines, MD Chief Quality Officer Crystal Run Healthcare July 16, 2015

AMGA Webinar: MSSP Final Rule Scott Hines, MD Chief Quality Officer Crystal Run Healthcare July 16, 2015

Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 >350 providers, >30 locations ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen ) 1999 Accredited by Joint Commission since 2006 (1 st in NY State) Level 3 NCQA PCMH since 2009

Crystal Run Healthcare ACO Single Entity ACO MSSP April 2012 NCQA ACO Accreditation 2012 (1 st in NY) Multiple Commercial Risk Based Contracts 35,000 patients attributed patients to CRHACO Crystal Run Health Plan 2015 MSO 2015

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Governance Structure ACO must be a legal entity For single entity ACOs, may use existing legal entity and governing structure For ACOs comprised of more than one participant, the ACO must be a separate legal entity and governing structure Strongly encourage 75% control of governing body by ACO participants Required beneficiary representation

Governance Structure (Con t) Managed by an executive that board can remove Medical director does not need to be an ACO provider ACO applicants must identify a qualified health care professional for ACO quality assurance & improvement

Governance Role Role of the governing body: Promote evidence-based medicine and patient engagement Promote care coordination Report on quality and cost measures Oversight and strategic direction of the ACO Must have a conflicts of interest policy for the governing body.

Governance Changes in participants/providers Required Reporting of ACO Participants ACO must report its participants at the start of each Performance Year ACO must report changes to its participant list within 30 days ACO must report its providers upon request A significant change is defined by a 50% change in ACO participants. CMS must be notified of a significant change and they may require additional information or drop ACO from program

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Beneficiary Assignment Assignment Aggregation of claims for services provided by ACO professionals, not just physicians within the ACO Ensures that assignment is based on services rendered during the performance year and not just the benchmarking year Greater flexibility if number of beneficiaries falls below 5,000

Beneficiary Assignment Include CCM and TCM codes as primary care services Include primary care providers in step 1 Include nurse practitioners, physician assistants, and specialists in step 2 Modification on which specialties will be included in step 2 Any changes to beneficiary assignment methodology will occur at the start of the PY

Beneficiary Assignment Included in Step 2 Code Specialty Name 03 Allergy 06 Cardiology 10 Gastroenterology 13 Neurology 16 Obstetrics/gynecology 17 Hospice and palliative care 23 Sports medicine 25 Physical medicine and rehabilitation 29 Pulmonary disease 37 Pediatric medicine 39 Nephrology 44 Infectious disease 46 Endocrinology 66 Rheumatology 70 Multispecialty clinic or group practice 82 Hematology 83 Hematology/oncology 84 Preventive medicine 90 Medical oncology 98 Gynecology/oncology

Beneficiary Assignment Not Included in Step 2 Code Specialty Name 02 General surgery 04 Otolaryngology 05 Anesthesiology 07 Dermatology 09 Interventional pain management 12 Osteopathic manipulative therapy 14 Neurosurgery 18 Ophthalmology 20 Orthopedic surgery 21 Cardiac electrophysiology 22 Pathology 24 Plastic and reconstructive surgery 26 Psychiatry 27 Geriatric psychiatry 28 Colorectal surgery 30 Diagnostic radiology 33 Thoracic surgery 34 Urology Code Specialty Name 36 Nuclear medicine 40 Hand surgery 72 Pain management 76 Peripheral vascular disease 77 Vascular surgery 78 Cardiac surgery 79 Addiction medicine 81 Critical care (intensivists) 85 Maxillofacial surgery 86 Neuro-psychiatry 91 Surgical oncology 92 Radiation oncology 93 Emergency medicine 94 Interventional radiology 99 Unknown physician specialty C0 Sleep medicine

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Claims Data Sharing Remove option to mail opt out forms Continue to mail notification that practice participates in MSSP All opting out must now occur by phone (1-800- MEDICARE) or at point of service Must have opt out forms at the point of service Must have signage at the point of service notifying beneficiaries that practice is participating in MSSP

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Minimum Savings Rate (MSR) & Minimum Loss Rate (MLR) For tracks 2 & 3 (downside risk) the ACO can choose No MSR/MLR Flat MSR/MLR between 0.5% - 2.0% (in 0.5% increments) Variable MSR/MLR based on number of assigned beneficiaries (same as track 1) MSR and MLR are always symmetrical

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Remaining in Track 1 Removed requirement that ACOs participating in Track 1 during first MSSP term must switch to down sided risk Can remain in Track 1 if the ACO met the quality performance standard in at least one of the first two years of their initial three year agreement Sharing rate remains at 50% for second term in MSSP program

Differences Between Track 2 & 3 Programmatic Differences Preliminary prospective attribution with retrospective reconciliation in track 2 vs. prospective attribution in track 3 No waivers in track 2 vs. SNF 3 day waiver in track 3 (possibly others in 2017)

Differences Between Track 2 & 3 Payment differences Category Track 2 Track 3 Sharing Rate Up to 60% Up to 75% Performance Payment Limit 15% of benchmark 20% of benchmark Shared Loss Rate Between 40%-60% depending on quality Loss Sharing Limit 5% in year 1 7.5% in year 2 10% in year 3 Between 40%-75% depending on quality 15%

Repayment Mechanisms Modification to Repayment Mechanisms Must demonstrate that ACO can repay 1% of per capita part A and B expenditures for attributed population Remove option to pay using reinsurance Escrow, line of credit, surety bonds Carry over shared losses into subsequent years rather than paying all at once

Outline Governance Beneficiary assignment Claims data sharing MSR/MLR Difference between track 2 and 3 (downside risk) Financial benchmarking

Financial Benchmarking Changes to financial benchmarking: Equally weight years 1-3 prior to PY Commence rulemaking later this year to include trend in regional spend so that ACOs are not penalized by their success NO change in effect of HCC scoring of continuously enrolled beneficiaries on benchmark

Financial Benchmarking HCC Newly assigned beneficiaries HCC score can adjust historical financial benchmark up or down Continuously assigned beneficiaries A falling HCC score can adjust historical financial benchmark down, but a rising score causes benchmark to remain the same No difference from current MSSP program (Nextgen ACO program is different)

MSSP Final Rule AMGA Webinar Series Karen Cabell, D.O. Department of Internal Medicine Chief Quality and Patient Safety Officer Health Care Education and Research

Welcome to Billings Clinic 2014 Caradigm. All rights reserved.

Mission & Vision Mission Health Care, Education and Research Vision Billings Clinic will be a national leader in providing the best clinical quality, patient safety, service, and value. 2014 Caradigm. All rights reserved.

Organizational Highlights Employ 3,750 employees Group practice with 310 Physicians, 100 PA/NPs Clinic & Hospital Joint Commission Accredited Magnet Designation for Nursing Excellence in 2006 and re-designation in 2011 Multi-specialty Physician Clinic 900,000 patient encounters 10 clinic locations Hospital & Sub Acute Care 285 Licensed Beds 14,500 hospital admissions/year Level II trauma center 42,000 patient ED visits/year Psychiatric Services Youth and Adult Hospital IP & OP Behavioral Health Clinic Aspen Meadows 90-Bed Long Term Care and 55-bed Assisted Living Facility Sub-Acute Care Research Center for Clinical Translational Research Clinical research Billings Clinic Foundation Over $100 million raised Over $48 million in current assets Over $69 million granted to Billings Clinic 30 2014 Caradigm. All rights reserved.

Montana: 147,138 Square Miles, 1,008,243 People 31 2014 Caradigm. All rights reserved.

Healthcare Foot Print: 350 Mile Radius Affiliate, Branch and Outreach Locations 2014 Caradigm. All rights reserved.

Our ACO Journey 2013 Start Medicare Shared Savings Program 2004-2012 CMS Physician Group Practice Demonstration Project & Transition Demo Sole Owners of largest Medicare Advantage Plan in Montana 2014 Start CMS Bundled Payment for Total Joints P4P Models and Shared Savings Models with other payers Self Insured Employee Plan 33 2014 Caradigm. All rights reserved.

Published in June 9, Federal Register Changes effective January 1, 2016 MSSP Track 1 Updates Changes to Beneficiary Assignment Methodology for Step 1 and 2 Equally weights the historical benchmark years and adds back savings for rebasing. Promises another rule on benchmarks this summer. Regional Benchmark vs. National Benchmark SNF-3-day stay waiver HCC Risk Adjustment

Changes to Track 1 Health Care, Education and Research

Track 1 Changes Removes requirement that Track 1 ACOs (1-sided) must transition to Track 2 (2-sided) after one agreement period. Does not reduce sharing rate to 40% for second contract, maintained at 50%. For Attribution: Still has Preliminary Prospective Assigned for Reports, with Retrospective Assignment for Final Quality and Financial Reconciliation. Health Care, Education and Research

Minimum Savings Rate for Track 1- Number of Beneficiaries No Change MSR (low end of assigned beneficiaries) MSR (high end of assigned beneficiaries) 5,000-5,999 3.9% 3.6% 6,000-6,999 3.6% 3.4% 7,000-7,999 3.4% 3.2% 8,000-8,999 3.2% 3.1% 9,000-9,999 3.1% 3.0% 10,000-14,999 3.0% 2.7% 15,000-19,999 2.7% 2.5% 20,000 49,999 2.5% 2.2% 50,000 59,999 2.2% 2.0% 60,000 + 2.0% Health Care, Education and Research

Changes to Attribution Methodology and Processes for ACO s to Identify their Providers Health Care, Education and Research

ACO Provider/ Patient Attribution Changes ACO professional Update Physicians in the ACO Adds other practitioners who are one of the following: A physician assistant, A nurse practitioner, or A clinical nurse specialist. Health Care, Education and Research

Attribution Changes Two step attribution process based on the plurality of primary care services furnished by: Step 1: Primary care physicians,» General Practice, Family Medicine, Internal Medicine, Geriatric Medicine, Pediatric Medicine (*New), PAs/ NPs with Primary Care Attribution (*New) Step 2: Specialist physicians, nurse practitioners, physician assistants, and clinical nurse specialists. Removes some specialty types whose services are not indicative of primary care services Will propose beneficiary attestation in 2017 Physician Rule Health Care, Education and Research

Attribution Changes- Specialties that Will Attribute patients to ACO Specialty Codes to be Used in Step 2 06 Cardiology 46 Endocrinology 12 Osteopathic 70 Multispecialty clinic or group practice 13 Neurology 79 Addiction medicine 16 Obstetrics/gynecology 82 Hematology 23 Sports medicine 83 Hematology/oncology 25 Physical medicine and rehabilitation 84 Preventive medicine 16 Psychiatry 86 Neuro-psychiatry 27 Geriatric psychiatry 90 Medical Oncology 29 Pulmonary disease 98 Gynecology/oncology 39 Nephrology Health Care, Education and Research

Attribution Changes- Specialties that Will NOT Attribute patients to ACO Allergy Dermatology Gastroenterology Hospice Infectious Disease Rheumatology Interventional Cardiology Surgical Specialties Health Care, Education and Research

Identification of ACO participants and providers/suppliers- *New Process ACO must submit to CMS at the beginning of the agreement and each performance year an up to the provider list ACO must notify CMS within 30 days of ACO participant or provider changes in PECOS. With Specialty codes for each Provider- Physician, PA, NP, etc. Health Care, Education and Research

Definition of Primary Care Services Primary care services defined as: No Change: 99201-99215, 99304-99340, 99341-99350, the Welcome to Medicare visit (G0402) Annual wellness visits (G0438 and G0439). Adds: Adds CPT codes 99495 and 99496 for transitional care management services. Adds CPT code 99490 for chronic care management services Future changes will be included in Physician Fee Schedule. Health Care, Education and Research

Changes to Benchmarking Methodology Health Care, Education and Research

Benchmarking- Changes in Final Rule In subsequent agreement periods, uses equally weighted previous 3 years to reset benchmark. MSSP Current 3 year weighted average 60%/ 30%/ 10% MSSP New Rule- 3 year weighted average 33%/ 33%/ 33% Adds back in prior period per beneficiary savings payments Health Care, Education and Research

Benchmark Changes Still Pending Most details still pending to be announced in summer 2015 Predicted-- new benchmarking rule this summer to: Reset benchmark based on a blend historical (30%) and regional (70%) FFS costs; Health Care, Education and Research

Skilled Nursing Facility 3 Day Waiver Health Care, Education and Research

NEW Payment Waiver for MSSP Skilled Nursing Facility Waiver FINALIZED for Track 3 2017 FINALIZED for NextGen ACO-- 2016 Eliminates requisite 3-day inpatient stay for coverage of inpatient SNF care (directly admitted or inpatient stay less than 3 days) Health Care, Education and Research

HCC Risk Adjustment Health Care, Education and Research

HCC Risk Adjustment MSSP- All Tracks Set at the beginning of the performance period and cannot increase for continuously enrolled beneficiaries HCC Score can increase with the addition of new beneficiaries NextGen ACO Can increase by up to 3% per year Health Care, Education and Research

15 to 20 ACOs Next Generation ACOs Minimum aligned beneficiaries: 10,000 (7,500 for rural ACOs) Two opportunities to apply: Second application due June 1, 2016 for January 1, 2017 start date. AMGA All Rights Reserved 14

Next Generation ACOs CMS Goals: Increased ACO financial risk; Long-term fiscal sustainability; Benchmark predictability and stability Prospective Benchmark ACO Opportunities: 1) Greater financial risk coupled with a greater portion of savings; 80% sharing rate (PY1-3, 2016-2018) 85% sharing rate (PY4-5, 2019-2020) 15% savings/losses cap 100% Risk Option More flexible payment options that support ACO investments in care improvement infrastructure to provide high quality care to patients Fee-for-service Population-based Payments Capitation in 2017 AMGA All Rights Reserved 14

MSSP Provisions in 2016 MPFS Proposed Rule CMS proposes the addition of a new measure called Statin Therapy for the Prevention and Treatment of Cardiovascular Disease in the Preventive Health domain of the MSSP quality measure set to align with PQRS CMS proposes to retain the flexibility needed to maintain or revert measures to pay for reporting if they no longer aligns with clinical practice or could cause harm

MSSP Provisions in 2016 MPFS Proposed Rule Clarification about how PQRS-eligible professionals participating in MSSP can meet their PQRS reporting requirements when their ACO reports quality measures Proposed new definition of primary care services to include claims submitted by Electing Teaching Amendment hospitals, but exclude claims with skilled nursing facility POS

Regulatory Process AMGA will be working with members who are interested in sharing their views to help us develop comments to CMS that reflect their concerns and suggestions Always looking for additional input, please contact Karen or Garrett Eberhardt of AMGA to join the Reimbursement and Payment Policy Team

Karen Ferguson kferguson@amga.org Garrett Eberhardt geberhardt@amga.org Thank you!