CMS

CMS Considers Overhaul to ACO Benchmarks

The federal government has rolled out an important proposal to revamp how Accountable Care Organization (ACOs) financial targets are set upon program renewal. The change influences whether an ACO, a health care entity composed of health care providers and hospitals coming together to coordinate care care for fee-for-service Medicare beneficiaries, may earn shared savings under program guidelines.

The rule, proposed by The Centers for Medicare and Medicaid Services (CMS), would shift from a national to a regional comparison model, readjusting the ACO’s benchmark from the prior performance period to reflect trends in fee-for-service costs for the ACO region. This is a departure from the current practice of updates based on national Medicare FFS spending for parts A and B Medicare.  The comment period for the rule closed March 28, 2016.

The benchmark is a reference point an ACO is measured against to determine whether Medicare fee-for-service costs were higher or lower than previous spending levels. It is a critical factor for calculating whether the ACO qualifies for shared savings.

National Rural ACO (NRACO) heard from its ACO participants that they are supportive of moving to the regional comparison model, arguing it will better reflect the health care environment in which the ACO operates.  The organization is seeking clarity from CMS regarding how its model of geographically-dispersed ACO participation would be evaluated under this model.  Read NRACO’s comment letter here.

This proposed rule is the latest of several program revisions since the program was enabled under the Affordable Care Act in 2010.   As of Jan. 1, 2016, there were are more than 400 ACOs participating in the Medicare Shared Savings Program, according to CMS, including the 23 that joined the program in 2015 through National Rural ACO’s participant network. The final rule is expected to be published this summer.

April 6, 2016 Accountable Care Organization, CMS Read more >

Rural Providers Organized Under 23 Medicare ACOs Receive $46 Million AIM Funding From CMMI

I would like to share this news release which was released to the news media today.

Lynn Barr

Rural Providers Organized Under 23 Medicare ACOs Receive $46 Million AIM Funding From CMMI

Additional $31 million also provided by CMMI to prepare rural practices for value-based payments under new Practice Transformation Network

Nevada City, CA, January 12, 2016 — A pioneering group of rural physicians and hospital administrators came together in 2013 to begin the journey toward managing rural population health. Through innovation and collaboration, they sought to transform today’s rural healthcare delivery system into a world-class primary care system that provides professional satisfaction for clinicians, attracts consumers, and provides high-quality acute, post-acute and outpatient services that meet patients’ needs.

These rural thought-leaders joined forces to form the first National Rural ACO (NRACO) and create the NRACO Services Corporation (NSC), which has been supporting rural Medicare ACOs with training, data, analytics, patient satisfaction surveys, and evidence-based medicine programs since 2014. In 2015, NSC organized more than 6,000 providers in 159 rural health systems into 23 Medicare Shared Savings Program (MSSP) ACOs, and obtained $46 million in ACO Investment Model funding to support their ACO operations and local care coordination programs. This group includes 55 rural PPS hospitals, 92 Critical Access Hospitals, 168 Rural Health Clinics, and 39 rural FQHCs serving more than 500,000 Medicare patients.

Working with other key stakeholders like the National Rural Health Association and the National Rural Health Resource Center, the rural hospital CEOs also started the non-profit National Rural Accountable Care Consortium. The Consortium will assist hundreds of rural health systems in their journey toward accountable care, funded by a $31 million cooperative agreement award from the Center for Medicare and Medicaid Innovation (CMMI).

To date, the majority of National Rural ACO participants have demonstrated reductions in per capita spending while improving quality and patient satisfaction. Unexpectedly, this has also resulted in financially strengthening the majority of the participating rural health systems. Participating hospital CFOs are queried monthly on the financial status of their organizations, and none have reported negative effects of being associated with accountable care, while most have described increased revenue and improved staff satisfaction.

According to NRACO founding member Tim Putnam, CEO of Margaret Mary Health in Batesville, Indiana, “there will be significant opportunities to strengthen rural health systems by becoming an ACO or participating in a CMMI innovation model in the next 1-2 years, but providers must prepare.” Co-founder Melanie Van Winkle, CFO of Mammoth Hospital in Mammoth Lakes, California agrees, saying “this is the reason we exist, to take care of the community. The ACO helps us focus on our mission.” Steve Barnett, CEO of McKenzie Health in Sandusky, Michigan adds, “once you begin giving this type of care, you’ll never go back. We are very grateful for the support we have received from CMS, CMMI, MedPAC, and the Federal Office of Rural Health Policy. We wouldn’t be able to organize rural providers under this model without their help.”

Today, rural providers can get all of the support they need to be ready for value-based payments through the Consortium’s Practice Transformation Network, fully funded by CMMI. Medical office staff will be trained in population health management, including care coordination, quality improvement, annual wellness visits, and patient satisfaction, and can begin billing for these professional services.

Spaces are still available to join the Consortium’s Practice Transformation Network. In order to enroll in this federally-funded program that provides a population health infrastructure to rural practices at no cost, go to http://www.nationalruralaco.com/ApplyNow.

Contact: Lynn Barr, Chief Transformation Officer

916-500-4777

email: admin@nationalruralaco.com

January 12, 2016 CMS, Healthcare Grants and Funding, News, Value-Based Payment Read more >

AHRQ Says Rural Quality is Subpar

So one of the debates out here is how does rural score in quality? Well, according to AHRQ’s Chartbook on Rural Health, not too good. The AHRQ publication released in August 2015 explains that rural counties report “worse” in the four of five NQF priorities: effective treatment, patient safety, healthy living and access when compared to their urban counterpart. Rural scores the “same” in patient centeredness but on no occasion does rural score “better”. In fact the more rural you get, the worse the quality scores. This is not good news for rural providers given the increasing reporting requirements on the horizon.

How does rural score on hospitalizations due to ambulatory care-sensitive conditions (ACSCs) such as hypertension and pneumonia that can be largely prevented if ambulatory care is provided in a timely and effective manner? You guessed it, not too good. According to the report, the rate of potentially avoidable hospitalizations for all conditions for people living in rural counties was higher than for residents living in metropolitan areas.

Same thing with Emergency Department utilization, the further you get away from the city the more people use the ED. AHRQ reports that the rate of ED visits per 100,000 was higher for rural residents when compared with urban. ED visits are costly and may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries. ED visits for conditions that are preventable or treatable with appropriate primary care lower health system efficiency and raise costs.

This data is very representative of what we see in our NRACO data and it is driving our services. Understanding your quality scores in preparation for value-based payment models must be a priority for all rural healthcare providers. How do you score?

 

by Sue Deitz, MPH, Regional VP, National Rural ACO

November 30, 2015 Accountable Care Organization, CMS, Value-Based Payment Read more >

National Quality Forum Calls for Mandatory Quality Reporting for Rural Providers

Participation in CMS quality measurement and quality improvement programs is mandatory for all rural providers”, according to a report released by the National Quality Forum’s Rural Health Committee. The NQF report, Performance Measurement for Rural Low-Volume Providers, outlines recommendations that transition rural providers into value based purchasing and is further evidence that rural performance measurement is here to stay. It is no longer a choice. Secretary Burwell’s laid the track when she announced that 30% of all Medicare provider payments will be tied to alternative payment models (e.g., accountable care organizations (ACOs), primary care medical home (PCMH) models, bundled payment arrangements, etc.) by the end of 2016 (50 percent by the end of 2018). HHS also seeks to tie 85 percent of Medicare fee-for-service payments to quality by 2016 (90 percent by 2018) through programs such as the Hospital Value-Based Purchasing and the Hospital Readmissions Reduction Program.

You can view the report here. 

The recommendations in the NQF report furthered our dialog of how we can accomplish Secretary Burwell’s goal given the challenges faced by the rural providers. Specifically, the report called for the need for rural-relevant measures that a can address low case volume explicitly and consideration of a sociodemographic risk adjustment It proposed the use a core set of measures, along with a menu of optional measures for rural providers and encouraged the measures that are used in patient-centered medical home models. It recommended performance be tied to incentive payments, not penalties. And most striking was the accelerated timeframe with the creation of incentive-only payment programs for rural providers within three years; and mandatory participation in CMS quality improvement programs within two to four years.

Rural providers have a legacy of policies and programs that often do not “fit” current local needs and often have misaligned incentives that undermine high-value and efficient care delivery. Cost-based reimbursement, for example, has not created incentives for value-based models that invest less in technology-intensive medical services and more in health promotion, care coordination, improved clinical care quality, enhanced patient safety and experience, and better population health at lower per capita costs. Nonetheless, rural communities have enormous potential for achieving the objectives of the Triple Aim. Smaller systems can be more nimble in making the kind of change necessary to succeed in the current environment.  New delivery arrangements may be pursued more easily among local clinical, behavior and public health providers who know and trust one another. Together, they share a collective interest in improving their community’s well-being. While the transition from the status quo will require a change in the balance and configuration of essential services, greater integration within and across service sectors, attention to population health, and shared governance and management structures, it is doable.   My take away – rural providers can no longer stay idle. The greatest threat to the sustainability of rural healthcare systems is not participating in rural performance measurement. The market will force doctors and patients to choose high value providers and partners – and rural will be left behind.

November 16, 2015 Accountable Care Organization, Care Coordination, CMS, Read more >

Summary of Key Rural Provisions in the 2016 Physician Fee Schedule

Following is a summary of the key rural provisions in the 2016 Physician Fee Schedule.

Advanced Care Planning:
CMS is approving new CPT codes 99497 (initial 30 minutes) and 99498  (subsequent 30 minutes) for explanation, discussion and completion of Advanced Directive forms for Medicare beneficiaries. The estimates of payment are $86 in an office setting and $80 in an inpatient setting. While this can now be part of the Annual Wellness Visit or a physician visit, and does qualify as an RHC visit, it cannot be billed in an RHC in addition to the All-Inclusive Rate.

Rural Health Clinics and HCPCS Codes:
RHCs will now be required to record all HCPCS codes for services provided during a visit, even though additional payment will not be forthcoming. It is essential that RHCs completely detail the services they provide. There is much debate about whether RHCs are not providing the same standard of care services as most fee-for-service clinics (such as smoking cessation counseling) or are they simply not documenting them because it does not affect payment. If you are doing the work, make sure you document it, or this could have negative consequences under payment reform. The new requirement for recording the HCPCS codes on the bill has been delayed from January 1st to April 1st 2016.

RHCs and FQHCs can Bill for Chronic Care Management (CCM) Codes:
Beginning in January 2016, RHCs and FQHCs can now bill $41.92 per patient per month under Part B for CCM services outside of the All-Inclusive Rate. Thanks, CMS! You heard our prayers.

New Quality Measure for the Medicare Shared Savings Program:
CMS is adding a new Statin Therapy for the Prevention and Treatment of Cardiovascular Disease in the Preventive Health domain.  The measure reports the percentage of beneficiaries whoe were prescribed or were already on statin medication dureing the measurement year and who fall into any of the following three categories: active diagnosis of clinical atherosclerotic cardiovascular disease, LDL-C > 190 mg/dl, or diabetics with LDL-C of 70-189 mg/dl. This new measure will be pay-for-reporting only for the next three years.

Changes in Assignment of Beneficiaries for the Medicare Shared Savings Program:
Primary care services that are delivered in a Skilled Nursing Facility (POS code 31) will no longer be considered for patient attribution.

To see all of the changes in the PFS, please go to https://www.federalregister.gov/articles/2015/11/16/2015-28005/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

November 2, 2015 Care Coordination, CMS, Healthcare Grants and Funding, Medicare Shared Savings Plan Read more >

National Rural Accountable Care Consortium is Awarded TCPI Grant to Support Rural Health

On September 29th, Secretary Burwell announced that our non-profit organization, the National Rural Accountable Care Consortium, was awarded up to $31 million to support 525 rural health systems across the country to prepare for Advanced Payment Models.

Our program is designed to assist rural providers in redesigning their ambulatory practices to maximize their success under the new value-based payment models. We will provide them the tools to set up a Medicare-billable care coordination program. These tools include the necessary IT infrastructure and a 24-hour Nurse Advice hotline. We use data from electronic health records to help providers facilitate and optimize their ambulatory quality scores. They can also use this data to redesign their practice workflow to improve care and lower costs. The Consortium also sets up ambulatory patient satisfaction surveys, engages with  physicians and leadership, and provides guidance on how to participate in and increase revenue through Advanced Payment Models.

We are very grateful for the support that CMS and CMMI is giving rural providers. Working together, we can provide better care for our community, reduce unnecessary costs, and improve the financial performance of our rural health systems. For more information about this program, please see the CMS website.

Click here to apply for the program. 

The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.  Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or its agencies.

October 2, 2015 Accountable Care Organization, CMS, Healthcare Grants and Funding Read more >

National Rural ACO Featured In HCPLAN Newsletter

I am excited to share this Q&A about the National Rural ACO and our work with ACOs that was recently featured in the HCPLAN Newsletter.

HCPLAN Newsletter | August 12 | Participant Spotlight: National Rural ACO (see pg. 4)

The National Rural ACO pools knowledge, patients, and resources so that independent community health systems can participate in new population health-based reimbursement models. Lynn Barr, MPH, Chief Transformation Officer, spoke with a member of the CAMH team on July 28.

[CAMH]: What is the National Rural ACO’s goal, and what key approaches are you using?

Barr: We focus only on rural communities. Though 20% of Medicare beneficiaries get care in rural America, these health systems are far behind in population health management. Many have not done care coordination, performance measurement, etc. Our goal is to help them make improvements in quality and cost. For example, their aggregate quality scores in 2014 were 60%. We want to get to 70-75% in year two and 80-90% in year three. We also aim to reduce costs by 10% within the first three-year cycle. For 2016, we’re putting in applications to CMS for 26 rural ACOs with 179 health systems in 32 states. Our biggest goal is getting people started on the journey of population health management. We are very excited about that.

Our first step is to set up care coordination in each community. Every member hires a care coordinator. This is great for the patients, and it helps lower costs and improve quality. Second, we add annual wellness visits. A provider can hit 11 quality scores in an annual visit. About 5O% of our members haven’t been doing annual wellness visits. It’s a billing issue. In other fee-for-service clinics, when a patient comes in for a regular visit, the provider can also do the wellness visit and bill for both. Rural providers and Federally Qualified Health Centers aren’t allowed to bill separately. That’s a huge disincentive. The third component is reducing Emergency Department (ED) utilization. Rural beneficiaries use the ED for primary care because rural providers aren’t available 24/7. Fifty percent of rural ED visits are for primary care. Total ED utilization per beneficiary is 20% higher than the national average. We want to bring that down significantly. Another component is analytics. We provide data to support the other three components. It makes a big difference. For example, we found that the cost of home health in one of our ACOs is $1000 per month, while the national average is just $300. There is a great opportunity to make a difference.

[CAMH]: Who can join? Is there a typical profile of a member?

Barr: All our members are “community health systems.” Typically there is one hospital with a group of affiliated physicians. Our goal is to take that delivery network and integrate it with others to improve performance and coordinate care.

[CAMH:] How much variety is there across your ACOs and why?

Barr: Rural providers are very diverse. Our hospitals range from 4 to 250 beds. Our communities have anywhere from 175 to 8,000 attributed patients, with the average being about 1,000 attributed lives.

[CAMH:] To what extent are rural health systems’ challenges unique?

Barr: One of the biggest differences is size. Almost all of these health systems don’t have the minimum 5000 attributed beneficiaries, which is why we need to combine them. They have extremely limited capital; lack of funding is a huge barrier. They also have very little IT infrastructure, so we have to provide it for them. Almost all have electronic health records. Rural providers are right up with the rest of the country for EHR adoption, but their EHRs are very simple. We use the Lightbeam Health population management system to pull all their claims data together with their clinical data. Data is critical. We get It to them quickly and show them how to use it. Their care coordination program is built around claims data.

[CAMH]: Are the components of your ACO approach different from what might work in urban ACOs?

Barr: Yes, they are very different from urban ACOs. The top rural health system concerns are building relationships with patients and building secondary and tertiary networks. They have few or no networks and highly fragmented care. For example, the 175 patients in our smallest community with were seen in 75 different Part A facilities in the last 2 years. Our focus is around engaging the community and, as a result, improving cost and quality. Urban ACO communities are huge. You can’t really understand the concept of community until you live and work in a rural hospital. Everyone shows up for a hospital board meeting and cares about their providers. In small communities, patients have deep relationships with their providers. We can succeed and thrive by serving their needs.

Urban ACOs don’t focus on community per se, because the ACO is just one of many players in town. Their patients change providers more often, so they focus on services they deliver and how to maximize cost and quality improvements. Our biggest advantage is that the patient population tends to be more stable. They may go other places for care, butthey tend to come back home. For example, if we do a good job on colorectal screening, we can wipe outcolorectal cancer in our town. That is very satisfying. Also, our approach wouldn’t work so well in urban settings where there is competition. There isn’t competition among our rural health systems, so it is easier to build collaboration. On the other hand, we are similar to urb an ACOs, insofar as this is a lot of hard work for everyone.

Barr: Our first ACO started in the 2014 performance year. By end of the first year, it had reduced utilization in every category except physician visits. It is too early to tell for the others. We only have 90 days of data so far, but there are some promising trends.

[CAMH] What in your mind are the most important lessons you’ve learned so far about standing up and running ACOs in rural health systems?

Barr: We changed the program quite a bit after the first year. We initially thought start up would be simpler. It takes a lot more interaction than we had assumed. We had to increase staffing to work more closely with each partner. It is more labor intensive, but rewarding. We really appreciate the support we are getting from the CMS Center for Medicare and Medicaid Innovation. We feel that they are committed to helping rural providersand to our success.

Click here to read the full newsletter,

September 4, 2015 Accountable Care Organization, CMS Read more >

CMS Wants to Hear From You!

CMS has released a Request for Information on transforming clinical practices. It is important for you to review this document and submit your comments to CMS no later than March 16, 2015. You can find the form to fill out here.

We must engage with CMS on these new payment models to define a unique approach for rural health systems. The National Rural ACO, a 501(c)3 organization governed by our founding members, supports a population health model where the rural health system is accountable for the care for its community. It preserves cost-based reimbursement, but allows us to earn more by coordinating care for our patients. The key elements of this model are that the community who lives in the primary service area of the hospital is assigned to the health system, who will proactively support them whether they get care locally or out of town. Critical to this model is the provision of Medicare claims data to the rural health system so we can identify patients who need our help, and also be able to evaluate the cost and quality of our referral network.

What are your ideas for payment reform? Let CMS know! And let us know, too. Rural providers need to lead the discussion. Submit your comments today!

March 4, 2015 Accountable Care Organization, CMS, Healthcare Policy, , Read more >

CMS Wants to Hear From You!

CMS has released a Request for Information on transforming clinical practices. It is important for you to review this document and submit your comments to CMS no later than March 16, 2015. You can find the form to fill out here.

We must engage with CMS on these new payment models to define a unique approach for rural health systems. The National Rural ACO, a 501(c)3 organization governed by our founding members, supports a population health model where the rural health system is accountable for the care for its community. It preserves cost-based reimbursement, but allows us to earn more by coordinating care for our patients. The key elements of this model are that the community who lives in the primary service area of the hospital is assigned to the health system, who will proactively support them whether they get care locally or out of town. Critical to this model is the provision of Medicare claims data to the rural health system so we can identify patients who need our help, and also be able to evaluate the cost and quality of our referral network.

What are your ideas for payment reform? Let CMS know! And let us know, too. Rural providers need to lead the discussion. Submit your comments today!

March 4, 2015 Accountable Care Organization, CMS, Healthcare Policy, , Read more >