• MSSP Final Rules Revision ACO Requirements Under Shared Savings Program – 2016 Revised MSSP Regulations Issues

On June 10, just in time for my birthday (thanks CMS), the Centers for Medicare & Medicaid Services (CMS) released final rules amending the regulatory requirement applicable to the Medicare Shared Savings Program (MSSP). The Final Rules that were published on June 10, 2016 state the intent to encourage additional participation in the program and to ease financial burdens on participating Accountable Care Organizations (ACOs). The regulations attempt to provide incentives for existing ACOS to renew their participation and elect to pursue higher levels of risk. The revised rules reflect an element of additional flexibility that ACOs may be able to take advantage of when transitioning between participation tracks.

There are a variety of changes in the new regulations. A few of these changes include:

• Clarifications regarding times that shared savings and shared loss claims may be re-opened by CMS.
• Changes in how benchmarks will be calculated beginning in 2017. (Increasing consideration of regional Medicare expenditures total population health of the population that is assigned to the ACO).
• Adoption of adjustments based on average fee-for-service Medicare expenditures applicable to the relevant regional service area for purposes of calculating benchmark adjustments. County-by-county averages will be utilized for expenditures attributable to the total cost of services to beneficiaries within the applicable county.
• Adoption of risk-adjustment factors when revising an ACO’s benchmarks. Risk adjustment is to be based on the relative health status of the ACO’s assigned population.
• Revision of the manner in which CMS performs truncating and trending calculations.

The new rules clarify that CMS has the authority to reopen and make revisions to MSSP payments in cases of fraud and for other similar reasons. Even when fraud does not exist, CMS will have four years after providing notice of initial determination of shared savings or loss to reopen and revise for any good cause. Unfortunately, there is not definition of what constitutes “good cause” in the new rules. In comments, CMS indicates that it will excercise this authority where there evidence that was previously unavailable evidence that indicates error in the original determination or where previously available evidence is clearly determined to have been relied on erroneously. This rather broad “reopening” authority presents significant financial uncertainty for ACOs.

Under the new rules, ACOs will now be able to remain in Track 1 for a fourth year before transitioning into Tracks 2 and 3 which involve higher degrees of risk. Additionally, ACOs that choose to progress to higher risk tracks will be able to have their benchmark recalculation deferred for an additional year. These changes are being made to make it easier for ACOs to transition to higher risk tracks.

Bundled Payment and ACO Arrangements – Clinically Integrated Payment Methodologies

Bundled payment involves an agreement between a provider group and a payor for the management of a defined segment of care for an agreed price. A bundled payment would include one payment for all providers involved in the episode of care that is within the bundled area. All providers providing care within the episode of care are entitled to be covered under the bundled payment.

The idea behind bundled payment is to place providers across the spectrum of the applicable care continuum at financial risk and to provide shared financial incentives. In theory, this forces otherwise disjointed providers to cooperate to better coordinate care and to coordinate at a higher level with other elements of the continuum of care.

Bundled payment is one of the primary reasons why providers are mobbing toward clinically integrated health care systems. CINs provide a mechanism for providers across the continuum of care to agree upon protocols and other mechanisms to help them be more cost efficient in the management of bundled areas of care while maximizing the quality of care and outcomes provided to patients.

The Center for Medicare and Medicaid Services has developed a Bundled Payment Program through its Innovation Center. (76 Fed Reg. 53, 137, August 25, 2011). The BPCI (Bundled Payment Initiative) creates four models for bundled payment under the Medicare program and provides some guidance regarding the models that may be offered in the private pay area. However, there is no guarantee the private models will follow the CMS model.

Bundled payments can be either prospective or retrospective in nature. Where the payment is retrospective, Medicare pays in a fee-for-service basis subject to later reconciliation if the episode of care is classified under a bundled payment category. Retrospective bundled payment is contrasted with prospective bundling where the bundling classification is defined in advance and one single, predetermined amount is paid based on the predetermined amount.

As mentioned above, clinically integrated organizations provide a useful mechanism to facilitate bundled payment mechanisms. Under the Medicare program, there are two potential roles that a CIN can be either an Awardee or a facilitator. An Awardee  agrees to assume payment risk under bundled payment initiatives. It is their responsibility to enter contractual arrangements with the full continuum of care that is required to service the bundled episode. Awardees must contract with “episode initiators: which can include physician groups, hospitals, and potentially other providers depending on the model of bundled care that is involved.

For more information on bundled payment mechanisms and structuring clinically integrated organizations, feel free to contact John Fisher in our health care practice group.

CMS Announces 89 New Accountable Care Organizations

The Centers for Medicare & Medicaid Services (CMS) has announced 89 new organizations that qualify to participate as Accountable Care Organizations (ACOs) under the Medicare Shared Saving Program.  The organizations were announced on July 9, 2012 and include the following organizations:

• Arizona Health Advantage, Inc, Chandler, Arizona
• John C. Lincoln Accountable Care Organization, LLC, Phoenix, Arizona
• Fort Smith Physicians Alliance ACO, LLC, Smith, Arkansas
• ApolloMed Accountable Care Organization Inc., Glendale, California
• Golden Life Healthcare LLC, Sacramento, California
• John Muir Physician Network, Walnut Creek, California
• Meridian Holdings, Inc., Hawthorne, California
• North Coast Medical ACO, Inc., Oceanside, California
• Torrance Memorial Integrated Physicians, LLC, Torrance, California
• MPS ACO Physicians, LLC, Middletown, Connecticut
• PriMed, LLC, Shelton, Connecticut
• Accountable Care Coalition of Northwest Florida, LLC, Pensacola, Florida
• Accountable Care Partners, LLC,  Jacksonville, FloridaAllcare Options, LLC, located in Parrish, Florida
• Florida Medical Clinic ACO, LLC,  Zephyrhills, Florida
• FPG Healthcare, LLC, Orlando, Florida
• HealthNet LLC, Boynton Beach, Florida
• Integrated Care Alliance, LLC, Gainesville, Florida
• Medical Practitioners for Affordable Care, LLC, Melbourne, Florida
• Palm Beach Accountable Care Organization, LLC, West Palm Beach, Florida
• Reliance Healthcare Management Solutions, LLC, Tampa, Florida
• WellStar Health Network, LLC, Marietta, Georgia
• Advocate Health Partners, Rolling Meadows, Illinois
• Chicago Health System ACO, LLC, Westmont, Illinois
• Deaconess Care Integration, LLC, Evansville, Indiana
• Franciscan AHN ACO, LLC, Mishawaka, Indiana
• Indiana University Health ACO, Inc., Indianapolis, Indiana
• Genesis Accountable Care Organization, LLC, Davenport, Iowa
• Iowa Health Accountable Care, L.C., Des Moines, Iowa
• One Care LLC, Des Moines, Iowa
• University of Iowa Affiliated Health Providers, LC, Iowa City, Iowa
• Owensboro ACO, Owensboro, Kentucky
• Quality Independent Physicians, Louisville, Kentucky
• Southern Kentucky Health Care Alliance
• TP-ACO LLC, Baton Rouge, Louisiana
• Central Maine ACO, Lewiston, Maine
• Maine Community Accountable Care Organization, LLC
• MaineHealth Accountable Care Organization, Portland, Maine
• Accountable Care Coalition of Maryland, LLC, Hollywood, Maryland
• Greater Baltimore Health Alliance Physicians, LLC, Baltimore, Maryland
• Maryland Accountable Care Organization of Eastern Shore LLC, National Harbor, Maryland
• Circle Health Alliance, LLC, Lowell, Massachusetts
• Harbor Medical Associates, PC, South Weymouth, Massachusetts
• Accountable Healthcare Alliance, PC, East Lansing, Michigan
• Oakwood Accountable Care Organization, LLC, Dearborn, Michigan
• Southeast Michigan Accountable Care, Inc., Dearborn, Michigan,
• Essential Health, Duluth, Minnesota
• Medical Mall Services of Mississippi, Jackson, Mississippi,
• BJC HealthCare ACO, LLC, St. Louis, Missouri
• Heartland Regional Medical Center, St. Joseph, Missouri
• Nevada Primary Care Network ACO, LLC, Las Vegas, Nevada
• Concord Elliot ACO LLC, Manchester, New Hampshire
• Barnabas Health ACO-North, LLC, West Orange, New Jersey
• Accountable Care Coalition of Syracuse, LLC, Syracuse, New York
• Asian American Accountable Care Organization, New York City
• Balance Accountable Care Network, New York City
• Beacon Health Partners, LLP, Manhasset, New York
• Chautauqua Region Associated Medical Partners, LLC, Jamestown, New York
• Healthcare Provider ACO, Inc., Garden City, New York
• Mount Sinai Care, LLC, New York City
• ProHEALTH Accountable Care Medical Group, PLLC, Lake Success, New York
• WESTMED Medical Group, PC, Purchase, New York
• Cornerstone Health Care, PA, High Point, North Carolina
• Triad Healthcare Network, LLC, Greensboro, North Carolina
• Mercy Health Select, LLC, Cincinnati, Ohio
• ProMedica Physician Group, Inc., Toledo, Ohio
• Summa Accountable Care Organization, Akron, Ohio
• University Hospitals Coordinated Care, Shaker Heights, Ohio
• North Bend Medical Center, Inc., Coos Bay, Oregon
• Coastal Medical, Inc., Providence, Rhode Island
• Accountable Care Coalition of The Tri-Counties, LLC, Charleston, South Carolina
• AnewCare LLC, Johnson City, Tennessee
• Cumberland Center for Healthcare Innovation, LLC, Nashville, Tennessee
• MissionPoint Health Partners,  Nashville, Tennessee
• St. Thomas Medical Group PLLC, Nashville, Tennessee
• Summit Health Solutions, Knoxville, Tennessee
• BHS Accountable Care, LLC, San Antonio, Texas
• Memorial Hermann Accountable Care Organization, Houston, Texas
• Methodist Patient Centered ACO, Dallas, Texas
• Essential Care Partners, LLC, Austin, Texas,
• Physicians ACO, LLC, Houston, Texas
• Texoma ACO, LLC, Wichita Falls, Texas
• Central Utah Clinic, P.C., Provo, Utah
• Accountable Care Coalition of Green Mountains, LLC, South Burlington, Vermont
• Polyclinic Management Services Company, Seattle, Washington,
• Aurora Accountable Care Organization LLC, Milwaukee, Wisconsin
• Dean Clinic and St. Mary’s Hospital Accountable Care Organization, LLC,  Madison, Wisconsin
• ProHealth Solutions, LLC, Waukesha, Wisconsin