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Accountable Care Organizations

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Accountable Care Organizations Preliminary Look at Proposed Regulations Oregon State Bar Health Law Section Brown Bag Lunch Discussion June 10, 2011 – PowerPoint PPT presentation

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Title: Accountable Care Organizations


1
Accountable Care Organizations Preliminary Look
at Proposed Regulations
Oregon State Bar Health Law Section Brown Bag
Lunch Discussion June 10, 2011 Peter D. Ricoy
2
Basis of presentation
  • CMS published proposed rule in federal register
    Thursday April 7, 2011.
  • Focus is on ACO organizational requirements
  • Not covered fraud abuse, antitrust waivers,
    IRS guidance, Pioneer Model
  • Final rules to be issued in the future means
    content in this presentation will be stale in
    future.

3
Outline
  1. Background of ACO Program
  2. ACO Requirements
  3. Quality Measures
  4. Savings
  5. Oregon CCO Concept
  6. Discussion

4
General Advice Hypotheticals
  • You are an attorney in private practice
    approached by each of the following wanting to
    know There was a news article about ACOs.
    Should I be doing something?
  • Physician Group
  • Hospital
  • Health Plan
  • Director of States Medicaid Program
  • Chair of State Workers Benefits Board
  • Physical Therapy Practice
  • Self-Funded ERISA Plan

5
General Advice Hypotheticals
  • Chiropractor
  • National Dental Practice
  • Naturopath
  • OIG Investigator

6
General Advice Hypotheticals
  • You are an attorney in private practice
    approached by each of the following wanting to
    know Is it a good idea for me to form or join
    an ACO or CCO?
  • Small Group, 3 Physician Primary Care Practice
  • Specialty 5 Physician Orthopedic Surgeons
  • Large Multispecialty Physician Clinic 150
    physicians, including primary care, dominant in a
    geographic area

7
General Advice Hypotheticals
  • Large multispecialty clinic, 150 physicians,
    no-primary care
  • Large Single Specialty Group of 50 Radiologists
  • Large Hospital in Urban Area, many employed
    physicians
  • Large Hospital in Urban Area, no/limited employed
    physicians
  • Only Hospital in rural county, no employed
    physicians
  • Staff-Model HMO-style Health Plan
  • PPO Health Plan Network only

8
Background Basis for Shared Savings Program?
  • Section 3022 of PPACA added section 1899 of
    Social Security Act to promote accountability for
    a patient population under Parts A and B
  • Program required to be established by January 1,
    2012
  • On November 10, 2010, CMS published a request for
    information (RIF) regarding accountable care
    organizations.

Reference 76 FR 19531
9
Background Why do we Need ACOs?
  • Current medical system
  • Fragmented services across providers
  • Little coordination of care
  • Pays for units of service rather than outcomes
    and
  • Holds no one organization or individual
    responsible for either the quality or cost of
    care.

Reference Congressional Research Service,
Accountable Care Organizations and the Medicare
Shared Savings Program, David Newman, November
4, 2010.
10
Background Estimated Impact of ACOs
  • Congressional Budget Office Estimated ACO Program
  • Reduce Medicare expenditures 4.9 billion over
    the 6 year period.
  • After two years, 20 of fee-for-service Medicare
    beneficiaries would be assigned to participating
    primary care physicians.
  • By 2019, 40 would be assigned.

11
Background Key Definitions
  • ACO Professional
  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • ACO Provider
  • Hospital
  • Skilled Nursing facility
  • Home Health Agency
  • Hospice
  • Others

ACO Participant ACO Provider (e.g. hospitals
others) ACO Supplier (e.g. physicians, others)
12
Background Who can be an ACO?
  • 5 Categories
  • ACO professionals in group practices
  • Networks of individual practices of ACO
    professionals
  • Partnerships or joint venture arrangements
    between hospitals and ACO professionals
  • Hospitals employing ACO Professionals
  • Other groups or providers and suppliers
    determined by CMS

Reference SSA Sec. 1899(b)
13
Emphasis on Physicians
  • The emphasis is on physicians rather than
    insurers or hospitals since physicians control
    (directly or indirectly) 87 of all personal
    health spending.
  • - CRS Report

Reference Congressional Research Service,
Accountable Care Organizations and the Medicare
Shared Savings Program, David Newman, November
4, 2010.
14
What is an ACO?
  • Legal entity
  • Comprised of eligible ACO Participants
  • Manage and Coordinate Care for Medicare
    fee-for-service beneficiaries
  • Establish mechanism for shared governance

Reference Proposed 42 CFR 425.4
15
Provider Payments Continue as Usual
Payments continue to be made to providers of
services and suppliers participating in an ACO
under original Medicare FFS program under Parts A
and B in the same manner they would otherwise be
made, except that a participating ACO is eligible
for shared savings payment.
Reference Section 1899(d)(a)(A) of SSA 76 FR
19532, 19602,
16
Assignment of Beneficiaries
  • (c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE
    BENEFICIARIES
  • TO ACOS.The Secretary shall determine an
    appropriate method to assign Medicare
    fee-for-service beneficiaries to an ACO based on
    their utilization of primary care services
    provided under this title by an ACO professional
    described in subsection (h)(1)(A).

17
Retrospective Beneficiary Assignment
  • Beneficiaries are assigned to an ACO based on
    their utilization of primary care services by a
    ACO-affiliated primary care physician
  • CMS will add up the total allowed charges for
    primary care services for each beneficiary for
    each ACO, and assign a beneficiary based on where
    beneficiary received a plurality of services.
  • Neither primary care providers nor specialists
    know whether a particular patient at treatment
    point is in ACO or not.

Reference Proposed 42 CFR 425.6.
18
How does an ACO qualify for a Shared Savings
payment?
  • 3 Key Requirements
  • Maintain ACO eligibility requirements
  • Meet quality performance standards
  • Exceed minimum savings rate

Reference Proposed 42 CFR 425.5(2)
19
Legal Entity Requirements
  • State law recognized legal entity
  • Perform key functions
  • receiving and distributing shared savings
  • repaying losses
  • meeting reporting requirements
  • ensuring ACO participants comply requirements
  • Unique TIN
  • Not necessarily enrolled in Medicare not
    necessarily licensed to practice medicine or
    provide clinical services

20
Governance
  • ACOs governing body
  • Must have adequate authority to execute ACO
    functions
  • Must accept responsibility for administrative,
    fiduciary, and clinical operations.
  • Must be comprised of
  • ACO participants or representatives
  • Medicare beneficiary representatives

Reference Proposed 42 CFR 425.5(8)
21
Governance (Continued)
  • At least 75 control of the ACOs governing body
    must be held by ACO participants.
  • Comment Leaves open possibility that 25 could
    be in control of health plan or management
    company.
  • Each ACO participant must choose appropriate
    representative and have appropriate
    proportionate control over governing body
    decision making.
  • Governing body must be separate and unique to ACO
    in cases where the ACO comprised multiple
    otherwise independent entities

Reference Proposed 42 CFR 425.5(8)
22
Can Existing Boards Qualify?
  • If the ACO is comprised of a single entity that
    is financially and clinically integrated, and if
    at least 75 percent control of the entitys
    governing body is comprised of representatives of
    the entity, the ACO governing body may be the
    same as the governing body of that entity,
    provided it satisfies the other requirements of
    this section

23
Leadership
  • Must be managed by executive whose appointment
    and removal are under control of governing body.
  • Must have leadership team that has demonstrated
    ability to influence or direct clinical practice
    to improve efficiency processes and outcomes.
  • Must have full-time senior medical director who
    is board-certified physician and on location.

Reference Proposed 42 CFR 425.5(9)
24
ACO Qualification Requirements
  • Clinical Integration. Must have a meaningful
    commitment to the ACOs clinical integration
    program to ensure likely success.
  • ACO participants have a meaningful financial or
    human investment in the ACO to motivate
    appropriate behaviors
  • Quality Assurance. Physician-directed quality
    assurance and process improvement committee must
    oversee program that established internal
    performance standards for quality, cost, and
    outcomes.
  • Evidence-Based Medicine. Must implement program
    to promote evidence-based medical practice or
    clinical guidelines.
  • Marketing Guidelines. All ACO marketing
    communications get approved prior to us.

Reference Proposed 42 CFR 425.5(9), (4)
25
ACO Qualifications (Continued)
  • Participant Agreement. Participants must agree
    to comply with guidelines and process, and ACO
    must have ability to expel those not meeting
    requirements.
  • Infrastructure IT. Must be able to collect and
    evaluate data and provide report cards to
    participants.
  • Compliance Plan. Must have a designated
    compliance official (not legal counsel). Comply
    with False Claims Act, anti-kickback statute,
    physician self-referal law, civil monetary
    pentalies law.
  • Sufficient Number of Beneficiaries and Providers.
    ACO must have an assigned population of 5,000 or
    more beneficiaries and a sufficient number of
    primary care physicians to support that
    population.

Reference Proposed 42 CFR 425.5(9), (10)
26
ACO Qualifications Continued .
  • Proof of Patient-Centered Focus. ACO must
    provide documentation of plans to
  • Promote evidence-based medicine
  • Promote beneficiary engagement
  • Internally report quality and cost
  • Coordinate care
  • Conduct CAHPS survey
  • Promote patient involvement in governance
  • Implement process for evaluating population
    health needs

Reference Proposed 42 CFR 425.5(15)
27
ACO Qualifications (Continued)
  • Proof of Patient-Centered Focus. ACO must
    provide documentation of plans to
  • Communicating clinical knowledge in a way that
    is understandable to them (plain English? Plain
    Spanish?)
  • Process for beneficiary engagement and shared
    decision-making that takes into account the
    beneficiaries unique needs, preferences, values
    and priorities.
  • Standards in place for beneficiary access and
    communication
  • Processes for measuring clinical or service
    perforance by physicians and using these results
    to improve care and service over time.

Reference Proposed 42 CFR 425.5(15)
28
ACO Qualifications Continued .
  • Distribution of Savings. A description of how it
    plans to distribute savings, achieve specific
    goals, and achieve better care, better health,
    and lower costs.
  • Three-Year Agreement. Can elect for Track 1,
    one-sided model for savings, or Track 2 for
    two-sided.
  • Reinsurance. ACO must obtain reinsurance, place
    funds in escrow, surety bonds, or line of credit
    to ensure repayment of losses under Track 2

29
Quality Measures
  • CMS selects the measures designated to determine
    an ACOs success in promoting
  • better care for individuals
  • better health for populations
  • lower growth in expenditures
  • CMS selects the quality performance standards
  • ACOs must submit data on the measures according
    to method established by CMS.

Reference Proposed 42 CFR 425.9.
30
Quality Measures
  1. Patient/caregiver experience (7 measures)
  2. Care coordination (16 measures)
  3. Patient safety (2 measures)
  4. Preventative health (9 measures)
  5. At-risk population/frail elderly health (31
    measures)

Reference Proposed 42 CFR 425.10 and 76 FR
19571-19591.
31
Quality Measures
  • Patient / Caregiver Examples
  • How well doctors communicate
  • Helpful, courteous, respectful staff
  • Getting timely care, appointments and information
  • Patients rating of doctor

32
Quality Measures
  • Care Coordination Examples
  • Hospital readmission rate within 30 days of
    discharge
  • Hospital discharge rate -- diabetes complications
  • Hospital discharge rate congestive heart
    failure
  • of physicians meeting HITECH Meaningful Use
  • of PCPs who are electronic prescribers

33
Quality Measures
  • Patient Safety Examples
  • Foreign object retained after surgery
  • Falls and trauma
  • Accidental puncture or laceration
  • Blood Incompatibility
  • Poor Glycemic Control

34
Quality Measures
  • Preventive Health Examples
  • Influenza Immunization
  • Pneumococcal Vaccination
  • Mammography Screening
  • Cholesterol Management
  • Blood Pressure Measurement

35
Quality Measures
  • At Risk Population Examples
  • Diabetes Aspirin Use, Tobacco Non-Use, Foot Exam
  • Heart Failure Weight Measurement, Beta-Blockers
  • Coronary Artery Disease Oral antiplatelet
    therapy, cholesterol, ACE Inhibitor
  • Hypertension Blood Pressue Plan of Care
  • Frail Elderly Osteoporosis management, INR
    testing

36
Calculating Quality
  • CMS Defines
  • Minimum attainment level
  • Performance benchmark
  • Each 5 domains is equally weighted
  • All measures within a domain must have a score
    above minimum attainment for the domain to be
    scored
  • If ACO satisfied the quality performance
    standards for one or more domains and savings,
    ACO may receive a proportion of shared savings.
  • CMS retains audit rights

37
Savings
  • Track 1
  • One-sided risk during first two years
  • Two-sided risk during third year
  • Two-sided risk thereafter
  • Track 2
  • Two-sided risk from start and going forward

Reference Proposed 42 CFR 425.10 and 76 FR
19571-19591.
38
Savings
  • Establishing Expenditure Baseline.
  • CMS identifies beneficiaries that would have been
    assigned to the ACO in most recent 3-year period.
  • Adjust for health status using CMS-Hierarchical
    Condition Categories.
  • Truncate per capita expenditures at 99th
    percentile to eliminate large claim variations.
  • Expenditures would be indexed using Medicare
    growth rates based on national spending growth
    levels (not local).
  • Adjustments for minimum savings rates to reduce
    random fluxuations based on the size of the ACO
  • 6-Month runout period

39
Savings (Continued)
  • One-Sided Risk
  • ACO receives up to 50 of Savings
  • Cap of 7.5
  • Two-Sided Risk
  • ACO receives up to 60 of Savings
  • Cap of 10

40
ACO vs HMO Key Differences
  • Patients Perspective No Gatekeeper Can still
    go to any Provider inside or outside of network.
  • Providers Perspective No Capitated Payments
    payments based on quality and savings

41
  • Oregons Coordinated Care Organizations
  • Based on Proposed Legislation, HB 3650

42
Oregon Coordinated Care Organizations Big
Picture
  • CCOs are a legislative concept passed by Oregon
    Special Joint Legislative Committee (HB 3650).
  • Intent is to creates a new and integrated health
    care delivery system for the Oregon Health Plan
  • Replace current system of managed care
    orgainizations
  • Federal waiver to address dual eligibles
    (Medicare / Medicaid).
  • Coordinates / integrates care among physical
    health, mental health, chemical dependency and
    dental health providers.

43
Oregon CCOs Big Picture
  • Global Budget for each CCO.
  • Significant rulemaking required in the interim,
    the authority shall renew the contracts of
    prepaid managed care health services
    organizations
  • In any area of the state where CCO not certified,
    OHA continues to contract with managed care
    organization
  • OHA may amend current contracts to allow prepaid
    managed care health services organizations that
    meet the criteria to become CCOs.

44
CCO Organizational Requirements
  • Oregon Health Authority to adopt by rule criteria
    for CCO.
  • CCO may be a single corporate structure or a
    network of providers organized through
    contractual relationships.
  • CCO must either be
  • (1) community-based organization or
  • (2) statewide organization with community-based
    participation in governance or
  • (3) any combination of the two.
  • Community means groups within geographic area
    served by CCO includes groups by age,
    ethnicity, race, economic status or other
    characteristic that may impact health care
    delivery

45
CCO Organizational Requirements
  • Governance Structure Must Include
  • Consumers of CCO Services
  • Persons that Share in the Financial Risk of the
    CCO
  • Major Components of health care delivery
    system and
  • Community at large.
  • CCO must convene a community advisory council,
    including community and county government
    representatives to ensure health care needs are
    being met

46
CCO Global Budget
  • Each CCO will have a fixed, global budget -- a
    total amount established prospectively by OHA to
    deliver care to all CCO members
  • OHA to develop global budgeting process
  • Legislative Fiscal Office not quantify fiscal
    impact yet news reports of savings in the second
    year of around 500 million in total funds
  • OHA to adopt a rule with safeguards to protect
    against underutilization service denials
  • Members and providers may appeal denials under
    contested case hearings

47
CCO Payment Mechanisms
  • OHA to Encourage CCO reimbursement (within the
    CCO system) methodologies
  • Reimburse on outcomes and quality
  • Hold providers responsible for efficiency
  • Reward good performance
  • Limit medical cost inflation
  • Promote prevention, person-centered care such as
    use of primary care homes
  • No reimbursement of never events
  • Transitional provisions for rural hospitals.

48
Network Issues
  • Members required to use CCO if available
  • Members have a choice of providers within network
  • Should Include providers of specialty care
  • A health care entity may not unreasonably
    refuse to contract with an organization seeking
    to form CCO if participation necessary to qualify
    as CCO
  • A health care entity that unreasonably refuses to
    contract with a CCO may not receive
    fee-for-service reimbursement from the authority
    for health services that are available through
    CCO
  • Providers may participate in multiple CCOs

49
CCO Quality Measures
  • OHA to develop outcome and quality measures
  • Must include ambulatory care, inpatient care,
    chemical dependency and mental health treatment,
    oral health care and other services
  • Must include demographic variables including race
    and ethnicity
  • Incorporate measures into contracts to hold the
    organizations accountable for performance and
    customer satisfaction
  • Information must be published, including quality
    measures, costs, outcomes, and other information
    necessary to evaluate value of CCO

50
List of Qualifications Aspirations
  • Members have relationship with a stable team of
    providers responsible for comprehensive care
    provided
  • Supportive and therapeutic needs of each member
    are addressed in a holistic fashion using patient
    centered primary care homes and individualized
    care plans
  • Transitional care when entering and leaving an
    acute care or long term care facility
  • Members receive navigational assistance through
    certified health care interpreters, community
    health workers, and personal health navigators

51
List of Qualifications Aspirations
  • Services geographically located as close to where
    members reside as possible
  • CCO uses health information technology to link
    services and providers across the continuum of
    care
  • CCO prioritized working with members who have
    high health care needs, multiple chronic
    conditions, mental illness or chemical dependency

52
List of Qualifications Aspirations
  • Providers work together to develop best practices
    for care and service to reduce waste and improve
    the health and well-being of members
  • Educated about the integrated approach
  • Emphasize prevention, healthy lifestyle choices,
    evidence-based practices, shared decision-making
  • Each member must be encouraged to be an active
    partner in directing the members health care
    and services
  • Members family should receive timely, complete
    and accurate information to participate in care
    and to have family knowledge, values, and
    cultural backgrounds respected

53
List of Qualifications Aspirations
  • Members must have access to competent advocates
    and assistance that is culturally appropriate
  • Must implement patient centered primary care
    homes require providers to communicate and
    coordinate using electronic health information
    technology

54
Other
  • Antitrust Intent to use State Action Doctrine to
    provide immunity from federal anti-trust laws
  • Study defensive medicine and make recommendations
    regarding caps on medical liability damages

55
  • Discussion .. Please Share Your Ideas!

56
Perspectives.(Big Picture)
  • Kathleen Sebelius
  • The Affordable Care Act is putting patients and
    their doctors in control of their health care,
    said HHS Secretary Kathleen Sebelius. For too
    long, it has been too difficult for health care
    providers to work together to coordinate and
    improve the care their patients receive. That has
    real consequences patients have gaps in their
    care, receive duplicative care, or are at
    increased risk of suffering from medical
    mistakes. Accountable Care Organizations will
    improve coordination and communication among
    doctors and hospitals, improve the quality of the
    care their patients receive, and help lower
    costs.

Reference http//www.hhs.gov/news/press/2011pres/
03/20110331a.html
57
Perspectives.(Big Picture)
  • Michael F. Cannon, Director of Health Policy
    Studies at the Cato Institute
  • Medicare's idea of encouragement is this If
    doctors and hospitals invest substantial
    resources to form an ACO, and better care
    coordination reduces the amount they bill
    Medicare, then the ACO will get to keep part of
    the savings.
  • "Here's a flash for the policy wonks pushing
    ACOs," writes industry expert Robert Laszewski.
    "They only work if the provider gets paid less
    for the same patient population. Why would they
    be dumb enough to voluntarily accept that
    outcome?

Reference Michael F. Cannon, ACO Debacle
Exposes Obamacare's Fatal Conceit (Guest
Opinion), Kaiser Health News, June 3, 2011.
http//www.kaiserhealthnews.org/Columns/2011/June/
060311cannon.aspx
58
Will Private Industry Follow CMS lead?
  • Hospital DRG reimbursement started out as a CMS
    payment policy.
  • Physician PPS started out as CMS payment policy.

59
Several National Health Plans Have Announced
Commercial ACOs ..
  • Cigna
  • Aetna
  • Humana
  • United Healthcare
  • Anthem Blue Cross Blue Shield

Will Oregon Health Plans Follow?
60
Perspectives..(Risk Models)
  • American Medical Association
  • The AMA urges CMS to provide a payment option
    that includes shared savings only (one-sided
    risk) without the mandatory shared loss
    provision. We believe an option allowing ACOs to
    receive shared savings, without the down-side
    risk, will encourage participation by a greater
    variety of physician practices.

Reference AMA letter to Donald Berwick, June 3,
2011.
61
Perspectives .(Complexity)
  • American Medical Group Association
  • Without dramatic changes to the proposed rule,
    it is our considered opinion that ACOs will be
    unsuccessful from inception and that the best
    opportunity for health care delivery reform in
    decades, and its potential for attendant
    improvements in care for millions of Americans,
    may be lost.
  • Determining attractiveness of ACO participation
    is a function of the sum of all of the
    requirements and conditions of participation
    measured against the likelihood of financial
    benefit, assessed in the context of meshing
    program and institutional goals. CMS has created
    a design specification encompassing onerously
    complex application and participation
    requirements coupled with unbalanced risk/reward
    criteria, that disadvantages ACO entities.

Reference AMGA letter to Donald Berwick, June 6,
2011.
62
Perspectives..OR WA
  • Oregon Association of Hospitals and Health
    Systems
  • Our key concern is that the proposed rules
    places handicaps on low cost states like Oregon
    that have a track record of providing care to
    Medicare beneficiaries at costs lower than the
    national average. This proposed rule sets a
    lower expenditure benchmark for low-cost regions
    like ours which will limit the achievable shared
    savings and increase the risk of exceeding the
    benchmark. We propose a methodology which would
    be equitable to states like Oregon and would not
    penalize them for historically keeping Medicare
    costs down. We suggest that CMS develop a
    low-cost state reward multiplier.

Reference OAHHS letter to Donald Berwick, June
3, 2011.
63
Perspectives OR WA
  • Washington State Hospital Association
  • We are concerned that many providers in
    Washington State have already taken significant
    steps to reduce cost and unnecessary services.
    Many providers in our state have lower
    utilization rates, when adjusted for acuity, than
    their counterparts in other areas of the country.
    These more efficient, less costly providers
    should not be disadvantaged when calculating
    shared savings payments. It is potentially more
    difficult for providers with lower overall costs
    per beneficiary to achieve significant savings in
    upcoming time periods.
  • CMS should create a shared savings model that
    also incentivizes more efficient, less costly
    providers to become an ACO. If the shared savings
    model does not take lower baseline spending into
    consideration, more efficient providers may not
    participate

Reference WSHA letter to Donald Berwick,
December 3, 2010.
64
Perspectives(Assignment)
  • American Medical Association
  • The AMA urges CMS to adopt a more flexible
    approach to beneficiary assignment to an ACO.We
    urge that instead of retrospective attribution,
    CMS should adopt a prospective approach that
    allows patients to volunteer to be part of the
    ACO and permits the ACOs to know up-front those
    beneficiaries for whom the ACO will be
    responsible.

Reference AMA letter to Donald Berwick, June 3,
2011.
65
Perspectives (Assignment)
  • American Medical Association
  • Consequently, CMS should seek to maximize the
    extent to which an ACO is held accountable only
    for those patients who voluntarily choose its
    physicians to provide or manage their care, and
    who are willing to allow the ACO to access data
    about the patients services. It should also seek
    to minimize or eliminate the use of statistical
    attribution methodologies, particularly
    retrospective attribution, after care has already
    been delivered. At a minimum, CMS should create
    one payment option that allows beneficiaries to
    elect participation in an ACO and makes
    ACO-related payments based only on the
    beneficiaries who make that election.

Reference AMA letter to Donald Berwick, June 3,
2011.
66
Perspectives (Governance)
  • Americas Health Insurance Plans
  • The proposed rule limits the role that health
    plans and other non-provider stakeholders can
    play in the formation and governance of ACOs. We
    question the practicality of CMS prescribing such
    an arbitrary governance standard. CMS focus
    should be ensuring that an ACOhas a demonstrated
    ability to treat individuals, improve population
    health, and create programs and perform outreach
    to reduce unnecessary care. To that end, ACOs
    should have the maximum amount of flexibility to
    create governing bodies that best meet their
    individual needs and help them achieve the
    intended goals of the MSSP, and should not be
    subject to a one-size fits-all approach to
    governance which would prohibit the establishment
    of potentially effective alternatives.

Reference AHIP letter to Donald Berwick, June 6,
2011.
67
Perspectives (Governance)
  • American Medical Group Association
  • Drop the requirement to have beneficiaries on the
    governing body, as this is unduly intrusive into
    the operations and organization of a private
    business, is impossible for many under state law,
    and a heavy burden for most.

Reference AMGA letter to Donald Berwick, June 6,
2011.
68
Perspectives (Cost Shifting)
  • Americas Health Insurance Plans
  • ACOs could have an incentive, and through the
    aggregation of market power an enhanced ability,
    to obtain shared savings payments by reducing
    Medicare expenditures to achieve savings under
    the MSSP and compensate for the reduced
    expenditures by charging higher rates and
    possibly reducing quality of care in the private
    market. This is not the intent of the ACA or the
    MSSP. Thus, the MSSP should require reporting by
    ACOs to determine whether such cost shifting is
    occurring, and any MSSP participants that engage
    in cost shifting should be terminated from the
    MSSP, or at a minimum, have their shared savings
    payments reduced by the amount of the cost shift.

Reference AHIP letter to Donald Berwick, June 6,
2011.
69
General Advice Hypotheticals
  • You are an attorney in private practice
    approached by each of the following wanting to
    know There was a news article about ACOs.
    Should I be doing something?
  • Physician Group
  • Hospital
  • Health Plan
  • Director of States Medicaid Program
  • Chair of State Workers Benefits Board
  • Physical Therapy Practice
  • Self-Funded ERISA Plan

70
General Advice Hypotheticals
  • Chiropractor
  • National Dental Practice
  • Naturopath
  • OIG Investigator

71
General Advice Hypotheticals
  • You are an attorney in private practice
    approached by each of the following wanting to
    know Is it a good idea for me to form or join
    an ACO or CCO?
  • Small Group, 3 Physician Primary Care Practice
  • Specialty 5 Physician Orthopedic Surgeons
  • Large Multispecialty Physician Clinic 150
    physicians, including primary care, dominant in a
    geographic area

72
General Advice Hypotheticals
  • Large multispecialty clinic, 150 physicians,
    no-primary care
  • Large Single Specialty Group of 50 Radiologists
  • Large Hospital in Urban Area, many employed
    physicians
  • Large Hospital in Urban Area, no/limited employed
    physicians
  • Only Hospital in rural county, no employed
    physicians
  • Staff-Model HMO-style Health Plan
  • PPO Health Plan Network only

73
Questions / Discussion
  • Peter D. Ricoy
  • Schwabe, Williamson, Wyatt, PC
  • 1211 SW 5th, Suite 1900
  • Portland, OR 97204
  • Email pricoy_at_schwabe.com
  • Phone 503-796-2973.
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