Saeed A. Khan MD, MBA, FACP © CureMD Healthcare ACOs and Requirements for Reporting Quality Measures © CureMD Healthcare Saeed A. Khan MD, MBA, FACP

What are Accountable Care Organizations Accountable Care Organizations are patient centered organizations Their goal is to provide individual patients seamless high quality care by the providers [physicians] and suppliers of services [hospitals, HHA, SNF and physicians] working together 2

Eligibility Requirements Must serve at least 5,000 Medicare Fee- For-Service [FFS] patients Participate for at least 3 years Not currently be enrolled in another shared saving program under FFS Medicare 3

ACO Models One Sided Model [sharing of 50% saving after meeting Minimum Saving Rate{MSR}] Two Sided Model [sharing of 60% of either saving or losses after meeting the Minimum saving Rate{MSR}] Both models are for the duration of the first agreement [3 years] 4

ACO Benchmarks CMS developed benchmarks which are an estimate of the total Medicare FFS costs for both Part A and Part B would have been for the ACO beneficiaries in the absence of an ACO The savings/loss is the difference between the estimated and the actual cost of caring for the Beneficiary The Benchmark is updated each performance year for the agreement period 5

Types of ACOs Hospital owned with employed physicians Hospital owned with both employed and independent physicians Health Plan/Insurance Company owned and partnered with independent physicians Physician owned and operated 6

Functions of ACOs Responsible for maintaining a patient centered focus Develop processes to promote Evidence Based Medicine Promote Patient Engagement Coordinate Care Internally and publicly report on Quality and Cost 7

Goals of ACOs Lower Health Care costs Meet 33 performance standards on Quality of Care Measures in 4 Key Domains of Care Achieved through a continuous quality improvement process 8

Domains of Care Methods of Data Submission 1).Patient/caregiver experience [7 measures] Measured by CMS survey 2).Care coordination/patient safety [6 measures] Measured by combination of claims/EHR Incentive program/GPRO Web interface 9

Domains of Care Methods of Data Submission 3). Preventive health [8 measures] Measured by GPRO web interface 4). At risk population [several sub groups] Measured by GPRO web interface 10

Preventive Care Measures Influenza Immunization Pneumococcal Vaccination Tobacco Use: Screening and Cessation intervention BMI screening and follow up Screening for Clinical Depression and F/U plan Colorectal Cancer Screening Breast Cancer Screening Screening for High BP and F/U documented 11

At-Risk Population Papulation Diabetes Mellitus [6 Measures] Hypertension [1Measure] Ischemic Vascular Disease [2 Measures] Heart Failure (HF) [1 Measure] Coronary Artery Disease (CAD) [2 Measures] 12

At Risk Population: Diabetes Hb A1C less than 8 LDL Cholesterol less than 100 Blood Pressure less than 140/90 Tobacco Non use Daily Aspirin or antiplatlet therapy for patients with associated Ischemic Vascular Disease 13

At Risk Population: Controlling Blood Pressure Blood Pressure of less than 140/90 14

At-Risk Population: Ischemic Vascular Disease Total Cholesterol less than 200 LDL Cholesterol less than 100 Use of Aspirin or antithrombotic medication 15

At Risk Population: Heart Failure Beta Blocker Therapy for Left Ventricular Systolic Dysfunction[LVSD] 16

At Risk Population: CAD Total Cholesterol less than 200 LDL Cholesterol less than 100 Use of ACEI/ARB in patients with Diabetes or LVEF less than 40% 17

ACO Quality Measures Before an ACO can share in any savings, it must demonstrate that it has met the Quality Measures for that year. Performance Year 1: Pay for reporting all 33 measures Performance Year 2: Pay for performance for 25 measures including all preventive and at risk [chronic disease management]and reporting of 8 survey measures 18

ACO Quality Measures Contd. Performance Year 3: Pay for performance applies to 32 measures and pay for reporting for 1 measure In the At Risk Domain with Diabetes and CAD it is a composite measure. All measures must be met for the Measure to be counted. Failure of even one measure will lead to the measure not being counted ACO must meet a minimum of at least 30% of the measures in each domain 19

Quality Scoring Point System Maximum of 2 points for each Quality Measure if EHR is used then it will be double weighted to maximum of 4 points Critical that EHR adoption be a core initiative The 3 composite measures [patient/ caregiver experience, Diabetes and CAD] have been collapsed into a maximum of 2 points 20

Point System within the Quality Performance Standard 21 Domain# of Individual Measures Total Measures for Scoring Purposes Total Possible Pts. per Domain Domain Weight (out of 100%) Patient/Caregiver experience 71 Measure with 6 survey module, plus 1 individual Measure 425% Care Co- ordination/patient safety 66 Measures, plus double wt. EHR measure [4 points] 1425% Preventive Health 88 Measures1625% At-Risk Population 127 Measures including Diabetes 5-Measure composite/CAD 2- Measure Composite 1425% Total %

Quality Scoring Sliding Scale 22 ACO Performance LevelQuality Points [all Measures except EHR] EHR Measure Quality Points 90+ percentile or 90+ % percentile or 80+ % percentile or 70+ % percentile or 60+ %

Quality Scoring Sliding Scale 23 ACO Performance LevelQuality Points [all Measures except EHR] EHR Measure Quality Points 50+ percentile or 50+ %1, percentile or 30+ % percentile or 30+ % Less than 30+ percentile or 30+ % No Points

Calculation of Quality Scoring 24 The higher the number the better the score The total points earned for Measures in each Domain will be added up and divided by the total points available This will produce the overall Domain Score which is the percentage of points earned versus the total points available This percentage will be applied to the MSSP rate[ 50%] to determine the shared savings payment up to the cap

Example of Quality Saving MSSP Rules Medicare gets half Total Saving /2= Shared Saving e.g. $5,000,000.00/2= $2,500, Saving is Quality Modified If the overall Domain Quality Score is 76.6% $2,500,000.00*76.6%= $1,917, Quality Impact $582,

How do we achieve our goal 26 Have the right EMR which will capture and be able to transmit the information. These Measures need to met at least once a year for Preventive Health. Consider an Annual Wellness Exam which will address it Consider seeing your At-Risk Patients at least 3-4 times a year and use the ACO provided tools to capture the Measure

Characteristics Necessary for your EMR to meet the Quality Measures 27 Have the built in Preventive Care Modules which will capture the necessary Measures. Develop a template to document the HOS Post capture have the e super bill populate the appropriate G code and auto populate subsequent visits unless changed Transmit the appropriate G Codes as most of the data collection is Claims Based Similar process for the At-Risk Measures

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