ACOs and Requirements for
Reporting
Measures
ACOs andQuality
Requirements
for
Saeed A. KhanQuality
MD, MBA,Measures
FACP
Reporting
Saeed A. Khan MD, MBA, FACP
© CureMD Healthcare
© CureMD Healthcare
What are Accountable Care Organizations
• Accountable Care Organizations are
patient centered organizations
• Their goal is to provide individual patients
seamless high quality care by the
providers [physicians] and suppliers of
services [hospitals, HHA, SNF and
physicians] working together
2
Eligibility Requirements
• Must serve at least 5,000 Medicare FeeFor-Service [FFS] patients
• Participate for at least 3 years
• Not currently be enrolled in another
shared saving program under FFS
Medicare
3
ACO Models
• One Sided Model [sharing of 50% saving
after meeting Minimum Saving Rate{MSR}]
• Two Sided Model [sharing of 60% of either
saving or losses after meeting the Minimum
saving Rate{MSR}]
• Both models are for the duration of the first
agreement [3 years]
4
ACO Benchmarks
• CMS developed benchmarks which are an
estimate of the total Medicare FFS costs for
both Part A and Part B would have been for the
ACO beneficiaries in the absence of an ACO
• The savings/loss is the difference between the
estimated and the actual cost of caring for the
Beneficiary
• The Benchmark is updated each performance
year for the agreement period
5
Types of ACOs
• Hospital owned with employed physicians
• Hospital owned with both employed and
independent physicians
• Health Plan/Insurance Company owned and
partnered with independent physicians
• Physician owned and operated
6
Functions of ACOs
• Responsible for maintaining a patient centered
focus
• Develop processes to promote Evidence Based
Medicine
• Promote Patient Engagement
• Coordinate Care
• Internally and publicly report on Quality and Cost
7
Goals of ACOs
• Lower Health Care costs
• Meet 33 performance standards on Quality of
Care Measures in 4 Key Domains of Care
• Achieved through a continuous quality
improvement process
8
Domains of Care Methods of Data Submission
• 1).Patient/caregiver experience [7 measures]
Measured by CMS survey
• 2).Care coordination/patient safety [6
measures]
Measured by combination of claims/EHR Incentive
program/GPRO Web interface
9
Domains of Care Methods of Data Submission
• 3). Preventive health [8 measures]
Measured by GPRO web interface
• 4). At risk population [several sub groups]
Measured by GPRO web interface
10
Preventive Care Measures
• Influenza Immunization
• Pneumococcal Vaccination
• Tobacco Use: Screening and Cessation
intervention
• BMI screening and follow up
• Screening for Clinical Depression and F/U plan
• Colorectal Cancer Screening
• Breast Cancer Screening
• Screening for High BP and F/U documented
11
At-Risk Population Papulation
•
•
•
•
•
Diabetes Mellitus
[6 Measures]
Hypertension
[1Measure]
Ischemic Vascular Disease
[2 Measures]
Heart Failure (HF)
[1 Measure]
Coronary Artery Disease (CAD) [2 Measures]
12
At Risk Population: Diabetes
•
•
•
•
•
Hb A1C less than 8
LDL Cholesterol less than 100
Blood Pressure less than 140/90
Tobacco Non use
Daily Aspirin or antiplatlet therapy for patients
with associated Ischemic Vascular Disease
13
At Risk Population: Controlling Blood Pressure
• Blood Pressure of less than 140/90
14
At-Risk Population: Ischemic Vascular Disease
• Total Cholesterol less than 200
• LDL Cholesterol less than 100
• Use of Aspirin or antithrombotic medication
15
At Risk Population: Heart Failure
• Beta Blocker Therapy for Left Ventricular
Systolic Dysfunction[LVSD]
16
At Risk Population: CAD
• Total Cholesterol less than 200
• LDL Cholesterol less than 100
• Use of ACEI/ARB in patients with Diabetes or
LVEF less than 40%
17
ACO Quality Measures
• Before an ACO can share in any savings, it must
demonstrate that it has met the Quality
Measures for that year.
• Performance Year 1: Pay for reporting all 33
measures
• Performance Year 2: Pay for performance for 25
measures including all preventive and at risk
[chronic disease management]and reporting of
8 survey measures
18
ACO Quality Measures Contd.
• Performance Year 3: Pay for performance applies to
32 measures and pay for reporting for 1 measure
• In the At Risk Domain with Diabetes and CAD it is a
composite measure. All measures must be met for
the Measure to be counted. Failure of even one
measure will lead to the measure not being
counted
• ACO must meet a minimum of at least 30% of the
measures in each domain
19
Quality Scoring Point System
• Maximum of 2 points for each Quality Measure
• if EHR is used then it will be double weighted
to maximum of 4 points
• Critical that EHR adoption be a core initiative
• The 3 composite measures [patient/ caregiver
experience, Diabetes and CAD] have been
collapsed into a maximum of 2 points
20
Point System within the Quality Performance Standard
Domain
# of
Individual
Measures
Total Measures for Scoring
Purposes
Total Possible
Pts. per
Domain
Domain
Weight
(out of
100%)
Patient/Caregiver
experience
7
1 Measure with 6 survey
module, plus 1 individual
Measure
4
25%
Care Coordination/patient
safety
6
6 Measures, plus double wt.
EHR measure [4 points]
14
25%
Preventive Health
8
8 Measures
16
25%
At-Risk Population
12
7 Measures including Diabetes
5-Measure composite/CAD 2Measure Composite
14
25%
Total
33
23
48
100%
21
Quality Scoring Sliding Scale
ACO Performance Level
Quality Points
[all Measures except EHR]
EHR Measure Quality
Points
90+ percentile or 90+ %
2
4
80+ percentile or 80+ %
1.85
3.7
70+ percentile or 70+ %
1.7
3.4
60+ percentile or 60+ %
1.55
3.1
22
Quality Scoring Sliding Scale
ACO Performance Level
Quality Points
[all Measures except EHR]
EHR Measure Quality
Points
50+ percentile or 50+ %
1,4
2.8
40+ percentile or 30+ %
1.25
2.5
30+ percentile or 30+ %
1.10
2.2
Less than 30+ percentile or
30+ %
No Points
No Points
23
Calculation of Quality Scoring
• The higher the number the better the score
• The total points earned for Measures in each Domain
will be added up and divided by the total points
available
• This will produce the overall Domain Score which is
the percentage of points earned versus the total
points available
• This percentage will be applied to the MSSP rate[
50%] to determine the shared savings payment up to
the cap
24
Example of Quality Saving
MSSP Rules
• Medicare gets half
Total Saving /2= Shared Saving
e.g. $5,000,000.00/2= $2,500,000.00
• Saving is Quality Modified
If the overall Domain Quality Score is 76.6%
$2,500,000.00*76.6%= $1,917,500.00
• Quality Impact $582,500.00
25
How do we achieve our goal
• Have the right EMR which will capture and be able to
transmit the information.
• These Measures need to met at least once a year for
Preventive Health. Consider an Annual Wellness Exam
which will address it
• Consider seeing your At-Risk Patients at least 3-4 times a
year and use the ACO provided tools to capture the
Measure
26
Characteristics Necessary for your EMR
to meet the Quality Measures
• Have the built in Preventive Care Modules which will
capture the necessary Measures.
• Develop a template to document the HOS
• Post capture have the e super bill populate the
appropriate G code and auto populate subsequent
visits unless changed
• Transmit the appropriate G Codes as most of the
data collection is Claims Based
• Similar process for the At-Risk Measures
27
Thank you and enjoy the
festivities!
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