HIMSS Patient-Centered Payer Roundtable April 21, 2011

Agenda WelcomeCall to Order and Roll Call (Paul Oates, Shelley Price) Topic discussionOverview of the ACO proposed rule (Shelley Price, HIMSS) Topic discussionPCPR Call for Volunteers for Teams (Jeffrey Pankow) Housekeeping(Shelley Price) Adjournment 2

Agenda WelcomeCall to Order and Roll Call (Paul Oates, Shelley Price) Topic discussionOverview of the ACO proposed rule (Shelley Price, HIMSS) Topic discussionPCPR Call for Volunteers for Teams (Jeffrey Pankow) Housekeeping(Shelley Price) Adjournment 3

Medicare Shared Savings Program Overview of Proposed Rule And HIMSS’ response process 4

ACOs: 3 Regulatory Actions CMS: Medicare Shared Savings Program (MSSP): Accountable Care Organizations (ACOs) – Proposed Rule; comments due June 6,2011 CMS & OIG: Waiver Designs in Connection with the MSSP and the Innovation Center – Notice w Comment Period; comments due June 6,2011 FTC & DOJ: Proposed Statement of Antitrust Enforcement Policy Regarding ACOs in the MSSP – Notice w Comment Period; comments due May 31,2011 5

ACOs: Definitions What is an ACO? – Must be a legal entity – Have an taxpayer identification number – Be comprised of eligible group of ACO participants 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 of providers of services and suppliers as determined by the Secretary – Have a mechanism for shared governance 6

ACOs: Program and Governance Program – Voluntary program; extensive application required – 3-year contract required; begins January 1, 2012 – Strong focus on primary care; PCP must be excl to 1 ACO – MU requirement: 50% of PCPs by yr 2 Governing Body – Broad authority & responsibility for administrative, fiduciary, & clinical operations – Proportional representation of ACO participants at least 75% are “participants”, i.e. providers such as MDs, PAs, NPs at least 1 Medicare beneficiary 7

ACOs: Beneficiaries Medicare FFS population Retrospective assignment to an ACO – Not an opt-in; assigned at the end of the year – Based on plurality of primary care to an ACO participant Patient may opt-out – ACO provider – PHI Minimum number of benes in ACO: 5,000 8

ACOs: Quality Reporting and Performance 65 measures – Patient/Caregiver Experience (7) – Care Coordination (16) – Patient Safety (2) – Preventive Health (9) – At-Risk Population/Frail Elderly (31) Required to Submit on all measures – Yr 1: report only – Yr 2-3: measured on performance 9

ACOs: Risk – 2 models 1-sided risk model – Yr 1-2: sharing in savings only; Yr 3: add in shared losses – Savings based on quality performance up to 50% savings – Yr 3 losses max: 5% – Bonus up to 2.5% for rural clinics, FQHCs 2-sided risk model – Yr 1-3: sharing in both savings & losses – Savings based on quality performance up to 60% savings – Yr 3 losses max: 10% – Bonus up to 5.0% for rural clinics, FQHCs 10

ACOs: Payment Benchmarking – Based on Pt A&B expenditure data for 3 yrs prior Minimum Savings Rate – ACO must achieve; confidence level re real savings – 1-sided: sliding scale, 3.9% (5K benes) – 2% (60K+ benes) – 2-sided: flat rate, 2% Net Savings Rate – 2% off the top to CMS Withholding: 25%; paid at end of yr 3 11

ACOs: By the Numbers Estimated Participation – ACOs: – Beneficiaries: M Costs and Savings (3 years) – Total savings: $510M (Federal) – Bonuses to ACOs: $800M – Penalties from ACOs: $40M – Average ACO startup cost incl 1 st yr operating: $1.73M 12

ACOs: Resources CMS website –

HIMSS Response ACO rule – Thursday, April 28 th – 90 minute call – outline – Thursday, May 5 th – 90 minute call – Thursday, May 12 th – 90 minute call – Wednesday, May 18 th – 90 minute call – Tuesday, May 24 th – Document out to Committees for review – Tuesday, May 31 st – Document from Committees and to the BoD – Friday, June 3 rd – Document from BoD – Monday, June 6 th – Submit to Government 14

Agenda WelcomeCall to Order and Roll Call (Paul Oates, Shelley Price) Topic discussionOverview of the ACO proposed rule (Shelley Price, HIMSS) Topic discussionPCPR Call for Volunteers for Teams (Jeffrey Pankow) Housekeeping(Shelley Price) Adjournment 15

Agenda WelcomeCall to Order and Roll Call (Paul Oates, Shelley Price) Topic discussionOverview of the ACO proposed rule (Shelley Price, HIMSS) Topic discussionPCPR Call for Volunteers for Teams (Jeffrey Pankow) Housekeeping(Shelley Price) Adjournment 16

Housekeeping The Call for Proposals for HIMS12: – open March 21 – May 23, – The Call for Reviewers for HIMS12: – open March 21-May 23, –

Wrap-up Web page – Next meeting – 3 rd Thursday of the month from 4-5pm EST Thursday, May 19,

Leadership and Contact Information Chairperson: Paul Oates Senior Enterprise Architect CIGNA Healthcare Vice Chairperson: Jeffrey Pankow Director, IT Excellus BCBS HIMSS Staff Liaison: Shelley Price Director, Payer and Life Sciences HIMSS 19