Objective 1 - Provider Reimbursement - SN110-15 - Final Rule MSSP

Question 1

Definition of accountable care organizations (ACOs)

Answer 1

1. ACOs are a new category of health care provider created by the ACA as part of the Medicare Shared Savings Program 2. Definition - a legal entity composed of certified Medicare providers and suppliers. These providers and suppliers work together to coordinate care for a defined population of Medicare FFS beneficiaries, and they have control over the ACO’s decision-making process. 3. ACOs that meet specified quality performance standards are eligible to receive payments for shared savings if they can reduce spending growth below target amounts 4. Medicare beneficiaries will be assigned to ACOs based on where they received certain primary care and preventative services in the most recent 12 months

Question 2

Eligibility requirements for ACOs to participate in the Medicare Shared Savings Program

Answer 2

1. Must be an eligible type of provider (see separate list) 2. Must be a legal entity capable of receiving and distributing shared savings, repaying shared losses, ensuring all providers comply with program requirements, and performing other required functions. 3. The governing body must be composed primarily (at least 75%) of participating providers and must also include Medicare beneficiaries served by the ACO 4. Leadership and management criteria include: a) Clinical oversight must be done by a senior-level medical director who is a board-certified physician b) Providers must make a meaningful financial or human investment to the clinical integration program 5. Must exhibit a strong patient-centeredness element (see separate list) 6. Must have a sufficient number of beneficiaries (at least 5,000) and primary care providers 7. Must have a compliance plan, a lead compliance official, and mechanisms for identifying compliance problems

Question 3

ACO Leadership and Management Structure

Answer 3

1. Operations are managed by and executive
2. Clinical operations are managed by a senior level medical director

Question 4

Providers eligible to participate in an ACO

Answer 4

1. Professionals in group practice arrangements 2. Networks of individual practices 3. Joint venture arrangements between hospitals and professionals 4. Hospitals employing professionals 5. Critical access hospitals that are paid by Medicare in a way that supports the collection of data needed to assign patients to providers 6. Rural health clinics 7. Federally qualified health clinics

Question 5

Overall ACO Goals

Answer 5

1. Promote evidence based medicine
2. Promote beneficiary engagement
3. Report on quality and cost metrics
4. Care coordination focused on patient centeredness

Question 6

Ways ACOs must demonstrate patient-centeredness

Answer 6

1. A beneficiary care experience survey 2. Patient involvement in ACO governance by representation in the governing body 3. A process for evaluating the health needs of the population 4. Systems in place to identify high-risk individuals and develop individualized care plans for targeted populations 5. A mechanism in place for coordination of care 6. A process in place for communicating clinical knowledge to beneficiaries in an understandable and actionable way 7. A process to allow beneficiaries to access their medical records 8. Processes for measuring clinical or service performance and using these results to improve care and service

Question 7

ACO Marketing Guidelines

Answer 7

1. All materials must be filed with CMS
2. Can be used if not disapproved in 5 days
3. Must certify in advance that all materials comply with regs
   
   1. Failure to comply violates patient centeredness requirements and the ACO will be placed on a corrective action plan