Accountable Care Organizations: A Guide for Professionals Spring 2016

Medicare Rights Center  The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives Page 2 © 2016 Medicare Rights Center

National Council on Aging  This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging Page 3 © 2016 Medicare Rights Center

This training will cover  Medicare basics  Accountable Care Organization (ACO) basics  The Medicare Shared Savings Program (MSSP)  Determining shared savings and losses  Receiving care from an ACO Page 4 © 2016 Medicare Rights Center

Medicare basics © 2016 Medicare Rights Center Page 5

 Health insurance for people age 65+ and people who have received Social Security disability benefits for 24 months  People of all income levels are eligible  Run by the federal government but can be provided by private insurance companies that contract with the federal government What is Medicare? Page 6 © 2016 Medicare Rights Center

Medicare eligibility: Age  Who is eligible for Medicare? Those 65+ years who:  Collect or qualify to collect Social Security or Railroad Retirement benefits, or  Are a current U.S. resident, and either A U.S. citizen OR A permanent U.S. resident having lived in the U.S. for 5 continuous years before applying for Medicare  NOTE: The 5 years may be reduced if the individual qualifies for premium-free Medicare Part A Page 7 © 2016 Medicare Rights Center

Medicare eligibility: Disability  Who is eligible for Medicare? Those under 65 years who:  Have been receiving Social Security Disability Insurance (SSDI) for more than 24 months OR  Have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and have qualified for SSDI OR  Have been diagnosed with End-Stage Renal Disease (ESRD) AND Are getting dialysis treatments or have had a kidney transplant; Have applied for Medicare benefits; and Have been deemed eligible for SSDI, railroad retirement benefits, or are otherwise considered to be fully insured by Social Security Page 8 © 2016 Medicare Rights Center

Parts of Medicare  Medicare benefits are administered through three parts Part A – Hospital/Inpatient benefits Part B – Doctor/Outpatient benefits Part D – Prescription drug benefit  Added 2006  What happened to Part C? Private health plans (e.g., HMO, PPO)  Way to get Parts A, B, and usually D through one private plan  Known as Medicare Advantage  Not a separate benefit  May cover services not covered by Parts A and B (i.e. Original Medicare), such as vision and dental care © 2016 Medicare Rights Center Page 9

ACO basics © 2016 Medicare Rights Center Page 10

What is an ACO?  A group of doctors, hospitals, and/or other health care providers that work together to provide coordinated care  ACOs aim to improve the quality of patient care while lowering the costs incurred by Medicare This is achieved by making providers financially accountable for the health of the beneficiaries they serve  ACOs receive incentives for providing better care to beneficiaries at a lower cost  An ACO may have to take on a greater share of financial losses when costs are not lowered © 2016 Medicare Rights Center Page 11

Coordinated care  The key way that ACOs are expected to save money is by coordinating patient care  Providers share information and decide treatment plans with input from the patient All providers working with a beneficiary communicate with one another, discuss issues they’ve treated, and build consensus around next steps Medicare also shares additional patient health information/records with providers (though patient can ask that Medicare not share such information) Beneficiaries should experience a reduction in repetitive care, for instance duplicated tests and having to fill out the same form multiple times © 2016 Medicare Rights Center Page 12

Who can receive care from an ACO?  Anyone with Original Medicare ACOs are not a different kind of health insurance plan (i.e. not a Medicare Advantage Plan, HMO, or Medigap) ACOs are networks of health care providers that work together with the aim of giving patients better care at a lower cost  Those with Medicare Advantage Plans cannot join an ACO  An individual can only be aligned with/assigned to one ACO  Even when in an ACO, patients can receive care from providers that are not part of the ACO © 2016 Medicare Rights Center Page 13

ACO models  Medicare Shared Savings Program (MSSP) The majority of ACOs are MSSPs This presentation will focus on MSSPs  Pioneer ACO model  Several new models have been announced Often serve specialized populations, introduce new features, and/or test variations on payment models © 2016 Medicare Rights Center Page 14

The Medicare Shared Savings Program (MSSP) © 2016 Medicare Rights Center Page 15

Medicare Shared Savings Program (MSSP)  Established by the Affordable Care Act (ACA)  MSSP ACOs are meant to facilitate cooperation among Medicare providers to increase the quality and decrease the cost of patient care Reward providers who are able to lower health care costs while providing their patients with better care Participation is voluntary for both providers and beneficiaries © 2016 Medicare Rights Center Page 16

Which providers can participate?  ACOs may consist of: ACO professionals* in group practice arrangements Networks of individual practices Partners or joint ventures between hospitals and ACO professionals Hospitals employing ACO professionals Other Medicare providers and suppliers as determined by the Health & Human Services (HHS) Secretary  An ACO must serve at least 5,000 Original Medicare beneficiaries and participate in the program for three years © 2016 Medicare Rights Center Page 17

What are shared savings?  The Centers for Medicare & Medicaid Services (CMS) has incentivized ACO participation by introducing shared savings models  CMS sets a benchmark for how much it should cost providers to care for their patients If a participating ACO’s costs fall below the benchmark (with positive health outcomes), they have created savings Savings are shared between CMS and providers, meaning that providers have a financial reason to reduce the overall cost of health care while continuing to deliver quality care © 2016 Medicare Rights Center Page 18

Shared losses  ACOs also have the option of sharing in the losses with CMS If total costs are above the benchmark, ACO is responsible for taking on a share of losses, rather than CMS paying them entirely Also called two-sided model (to be discussed later)  ACOs that elect to share in the losses are eligible for a greater portion of shared savings Taking on higher risks for greater rewards © 2016 Medicare Rights Center Page 19

Quality performance scoring  Before an ACO can share in any savings, must demonstrate that it has met the quality performance standard  Graded on the quality of patient care  33 measures that ACOs must report on  ACO patients also weigh in through satisfaction surveys © 2016 Medicare Rights Center Page 20

Quality measures  Measures broken into four categories: 1.Patient/caregiver experience 2.Care coordination/patient safety 3.At-risk population 4.Preventive care (i.e. screenings)  Data reported through claim and administrative data, clinical measure data, and patient experience of care surveys © 2016 Medicare Rights Center Page 21

Patient experience surveys  Beneficiaries who receive care through an ACO can share following information via surveys: Getting timely care, appointments, and information How well their providers communicate Rating of their provider Access to specialists Quality of health promotion and education Shared decision-making Their health status following care Availability of additional health care resources through ACO © 2016 Medicare Rights Center Page 22

Determining shared savings and losses Page 23 © 2016 Medicare Rights Center

Benchmark  To determine an ACO’s shared savings and losses each year, CMS compares ACO performance to a set benchmark Prediction of what the Part A and B expenditures for fee-for- service beneficiaries would have been Adjusted for ACOs whose beneficiary population may on average require more care*  If ACO expenditures fall below benchmark, it has created savings; if above benchmark, it has produced losses © 2016 Medicare Rights Center Page 24

One-sided & two-sided models  One-sided model These ACOs may earn up to 50% of savings they create by keeping prices below benchmark Savings also dependent on quality performance  Two-sided model These ACOs may earn up to 60% of savings they create Savings also dependent on quality performance May also incur shared losses if total expenditures are above benchmark  ACOs with higher quality scores owe a smaller percentage of the losses than those with low quality scores © 2016 Medicare Rights Center Page 25

Phased pay for performance  Each year in MSSP, ACO must meet certain requirements to be eligible for shared savings  Number of quality measures that an ACO must meet to receive payments increases over time Year one: ACO must only report all 33 measures to receive shared savings Year two: Pay for performance applies to 25 measures while pay for reporting applies to the other eight Year three: Pay for performance applies to 32 measures* © 2016 Medicare Rights Center Page 26

Receiving care from an ACO Page 27 © 2016 Medicare Rights Center

How do patients participate in ACO?  Patient whose provider is part of ACO must receive notification A letter Notice posted or given in writing in provider’s office In-person communication with provider  Only those with Original Medicare can be part of ACO Those with Medicare Advantage are excluded, though they can still see providers that are part of an ACO (their outcomes just cannot be counted toward ACO reporting)  Beneficiaries can still see non-ACO providers ACO assignment is for determining shared savings/losses Assignment does not mean the beneficiary can only use their ACO Page 28 © 2016 Medicare Rights Center

Assignment to an ACO  Two ways, each involving where the majority of a beneficiary’s Medicare claims come from: Original Medicare beneficiary receives plurality of their primary care services from primary care physicians within ACO Beneficiary receives plurality of their primary care services from specialist physicians or certain non-physician practitioners* within the ACO  Being assigned to ACO is also referred to as being aligned with ACO  If unsure of whether their provider is part of ACO, beneficiary can call MEDICARE Page 29 © 2016 Medicare Rights Center

The patient experience  ACOs aim to avoid unnecessary duplication of care to reduce costs, meaning beneficiaries may find the following changes in their medical experience: All providers will know what medical services they’ve received in ACO Fewer repeated medical tests Fewer forms to fill out (only fill out forms once)  Beneficiaries may be asked to fill out surveys  Providers will involve the beneficiary in making care decisions Shared decision-making Individualized care plans © 2016 Medicare Rights Center Page 30

Shared decision-making  Means ACO professionals must take into account a beneficiary’s: Unique needs Preferences Values Priorities  ACOs required to promote beneficiary engagement in numerous ways, including shared decision-making  Each ACO may have different process for engaging beneficiaries in shared decision-making Page 31 © 2016 Medicare Rights Center

Individualized care plans  Developed by a beneficiary and ACO professionals  Specific to beneficiary’s needs Meant to improve health care outcomes, especially for high- risk patients and those with multiple chronic conditions Beneficiary should be at the center of the process  ACO applicants must submit descriptions of their individualized care program to CMS Includes criteria for creating plan Beneficiaries may have varying experiences with individualized care plan because each ACO may have different process for developing plans Page 32 © 2016 Medicare Rights Center

Basic beneficiary rights  Getting care at an ACO does not change a beneficiary’s rights, including: Freedom to choose one’s Medicare provider Ability to seek a second opinion Filing complaints Appeal rights  Beneficiaries have the right to opt out of ACO Page 33 © 2016 Medicare Rights Center

Beneficiary privacy rights  ACOs share patient information among providers and receive additional information from Medicare about their patients Information used to provide beneficiaries with high-quality, coordinated care  Beneficiaries can request that Medicare not share their medical information with ACO To do so, call MEDICARE Medicare requires written permission from a beneficiary to share their information in the ACO if they are receiving or have received treatment for drug or alcohol abuse Page 34 © 2016 Medicare Rights Center

Differences between MSSP and Pioneer models  The Pioneer ACO model include a few notable differences from MSSPs: Pioneer ACOs must be responsible for at least 15,000 beneficiaries (5,000 in rural areas) Pioneer ACOs are allowed to take on higher levels of risk for larger portions of any created savings Certain Pioneer ACOs may elect or have elected to use a population-based payment model Pioneer ACOs are testing a voluntary beneficiary alignment process*  Patients retain the same rights, no matter the ACO model © 2016 Medicare Rights Center Page 35

Information for dual eligibles  In certain states, there are Financial Alignment Demonstrations for beneficiaries with both Medicare and Medicaid  These demonstrations use one of two models to provide better care for duals (i.e. those with Medicare and Medicaid) Capitated model* Managed fee-for-service model**  Participants in capitated model demonstrations are ineligible for assignment to an ACO Page 36 © 2016 Medicare Rights Center

For more information and help  Local State Health Insurance Assistance Program (SHIP)  Social Security Administration  Medicare MEDICARE ( )  Medicare Rights Center  National Council on Aging © 2016 Medicare Rights Center Page 37

Medicare Interactive  Medicare Interactive  Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: “How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare?” 2 million annual visits and growing © 2016 Medicare Rights Center Page 38

Medicare Interactive Pro (MI Pro)  Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare Four levels with four to five courses each, organized by knowledge level Quizzes and downloadable course materials  Builds on 25 years of Medicare Rights Center counseling experience  For details, visit center/courses or contact Jay Johnson at or © 2016 Medicare Rights Center Page 39

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