Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform

1. Virginia Physical Therapy Association2012 Annual ConferenceHealth Care Reform Gillian Russell, JD Senior Regulatory Affairs Specialist American Physical Therapy Association

2. HCR / Goal of Integrated CareThree Part Aim

3. Emerging Themes in Health Care

4. Timeline of Key Health Reform Provisions

5. Collaborative Care Models:Accountable Care Organizations(ACOs)

6. What is an Accountable Care Organization (ACO)? • Networks of physicians, hospitals and other providers that will be incentivized to work together to provide quality care and lower growth in health care costs under Medicare FFS • Goal is to provide seamless, high quality care instead of fragmented care in the current FFS model

7. ACO Final Rulemaking

8. Highlights of MSSP Final Rule

9. ACO Multiple Pathways

10. ACO Resources • 116 MSSP ACOs • 32 Pioneers • 20 Advanced Payment

11. Eligible Participants • ACO Professionals in Group Practice Arrangements • Networks of Individual Practices of ACO Professionals • Partnerships or Joint Venture Arrangements Between Hospitals and ACO Professionals • Hospitals Employing ACO Professionals • Critical Access that bills for facility and professional services • Federally Qualified Health Centers • Rural Health Clinics

12. ACO Definitions

13. ACO Structure • Formal and legal structure and allows the ACO to receive and distribute payments for shared savings • Formal CMS application and approval process • Representatives from Medicare FFS beneficiaries and each ACO provider/ participant • Allows for partnering with private entities but ACO participants must have at least 75 percent control of the ACO’s governing body

14. ACO Structure • Evidence-based medical practice or clinical guidelines • Three-year contractual commitment (remedial actions for removing participants for non-compliance) • 5000 yearly patient threshold • Participation voluntary for providers and patients

15. Establishing a Benchmark • Current Medicare FFS payment • Shared savings payments directly to the ACO • Benchmark developed to assess performance • An estimate of total Medicare FFS Parts A and B costs if provided absent ACO • Benchmark factors in patient characteristics, geographic location, etc. • Benchmark updated each year of the three-year period

16. Risk Models • Minimum savings rate based on percentage of the benchmark that the ACO must exceed • ACOs must opt into one of two risk-sharing models: • One-sided Risk (up to 50% shared savings and <10% of benchmark) • Two-sided Risk Model (up to 60% shared savings and <15 percent of benchmark, up to 10 % shared losses)

17. Beneficiary Assignment • Plurality test for determining beneficiary assignment to an ACO • Whether a beneficiary receives more primary care from that ACO than from any other provider

18. ACO Quality: The Measures • Total of 33 measures (scored as 23) • 4 domains • Better care for individuals • Better health for population • 4 methods of data submission • Patient survey • Claims • EHR • Group Physician Reporting Option (GPRO) • Measures will be phased in from pay for reporting to pay for performance

19. ACOs and Quality • Quality reporting overview: • ACOs must report and meet quality measure standards for the contracted three years • Quality reporting will include mix of measures: • Evidence-based care process • Outcome • Patient experience • CMS did not include utilization measures as the ACO program will address this through improved coordinated and quality

20. ACO Quality Reporting: Therapy Considerations

21. Interim Final Rule on Fraud and Abuse Waivers • 5 final waivers: • ACO pre-participation • ACO participation • Shared Savings Distribution • Compliance with Physician Self-referral Law • Patient incentive • Applies a “reasoned approach analysis” • Existing exceptions and safe harbors still apply

22. Anti-trust Enforcement Policy • Establishes an anti-trust “safety zone” • Combined share of 30% or less of each combined service PSA • Exception for rural ACOs • “Safety Zone” designation stays in effect for duration of ACO agreement • ACOs outside of “safety zones” not necessarily unlawful

23. Private ACO Collaborations

25. Dispelling the Myths Myth Reality ACOs have significant quality, governance and marketing requirements Providers will still submit claims to Medicare Patients/ providers can receive care outside ACO ACOs do not affect Stark IOAS exception but does pose significant issues • ACOs are the same as the HMOs of the 1990s • ACOs will replace Medicare FFS and providers will be paid by the ACO • Patient choice is taken away • ACOs widen the door for POPTs

26. Physical Therapy Considerations

27. What Do ACOs Mean for PT Practice? ACO Physical Therapists Practicing Outside of ACO Model Physical Therapists Practicing Within ACO Setting

28. Is an ACO Partnership Right for Your Practice?

29. CMS Resources • CMS Shared Savings Program http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/ • CMMI Pioneer and Advanced Payment Model http://innovations.cms.gov/initiatives/ACO/index.html

30. Key Points for Therapists • Can contract with multiple ACOs • ACO activity and composition will vary • ACOs are voluntary • ACO final rules do not relax Stark II IOAS exception • Know differences in MSSP, Pioneer, and Private ACOs • Participation in quality initiatives and collection of outcomes data is crucial • Assess interoperability of current and potential EMRs

31. Collaborative Care Models:Bundled Payments

32. Section 3023 of ACA: Bundling • Bundling Pilot Project – national, voluntary pilot program • Hospitals, physicians and post-acute care providers (SNFs, home health, IRFs, and LTCHS) • Improve patient care and cost-savings through bundled payment model • Must be established by 2013 and will last for five years • Episode of care: 3 days before admission to hospital, through LOS, and end 30 days post discharge • Based on eight selected conditions • Quality measures/assessment tool to be established • Medicaid bundled payment demo to take place in eight states

33. CMMI: Bundling Payment Initiative • Designed to encourage doctors, hospitals and other health care providers to coordinate care • Objectives: • Support and encourage providers through three part aim • Decrease the cost of an acute episode of care and the associated post-acute care while improving quality • Develop and test new payment models for three-part aim • Shorten the cycle time for adoption of evidence-based care

34. Bundling Initiative: Four Proposed Models

35. Relationship between Bundling Initiative and Pilot Project • Bundled Payments for Care Improvement initiative is a separate activity • Consistent with goals of National Pilot Program on Payment Bundling authorized by ACA • Bundled initiative will help inform future work under the pilot project

36. Definition of Bundled Payments • Single payment made for a defined group of services. • May cover services furnished by a single entity or items and services furnished by several providers in multiple care delivery settings. • Single negotiated episode payment of a predetermined amount for all services. • Paid prospectively or retrospectively. Source: CMMI Website FAQs

37. Example Bundled Payment • Medicare and the provider would agree to a bundled payment target price for acute care hospital services for an inpatient stay plus professional services and post-acute care related to the principal reason for the hospitalization, rather than paying separately for each physician visit and procedure provided during the episode.

38. Bundling Key Focus: Reduction in Hospital Readmissions • Implementation of reduction measures in key acute and post acute care settings: • Inpatient hospitals • Inpatient rehabilitation facilities (IRF PPS 2012) • Transitioning focus in home health, skilled nursing facilities, and LTCHs • Private initiatives define readmissions – United Healthcare and Geisinger

39. Hospital Readmissions Reduction • The Patient Protection and Affordable Care Act (PPACA) established the Hospital Readmissions Reduction Program. • Begins in 2013, and is aimed at adjusting hospital payments for those institutions that have higher than expected readmissions.

40. Hospital Readmissions Reduction Program • Program to reduce payments for facilities exceeding certain rate of readmissions • Proposed Rule: August 18, 2011 • Implementation: October 2012 • Condition specific 30-day readmissions • Acute myocardial infarction (AMI) • Heart failure (HF) • Pneumonia (PN)

41. Hospital Readmissions Reduction Program • Additional conditions to be added • As determined by Secretary for FY2015 • Chronic obstructive lung disease, coronary bypass grafting, percutaneous coronary interventions, other vascular procedures (as identified in 2007 MedPAC report) • P4P • Withholdings up to 1% FY2013, 2% FY2014, and 3% FY 2015 and beyond

42. Additional Readmissions Measures

43. APTA Readmissions Efforts • Increased member education regarding through a variety of educational sessions including: • The Value of Physical Therapy in Reducing Avoidable HospitalReadmissions (audio conference) • Medicare update presentations (CSM & Annual Conference) • Coding, Payment and Practice Applications Seminars • Creation of new readmission page on the website: http://www.apta.org/HospitalReadmissions/ • Submission of comments by APTA on a variety of payment regulations and measurement methodologies related to readmissions

44. Collaborative Care Models:Patient-Centered Medical Homes(PCMHs)

45. Medical Homes • Redefining primary care • Primary care medical home accountable for meeting the large majority of each patient’s physical and mental health care needs • Prevention and wellness, acute care, and chronic care • Team approach: physicians, nurses, physical therapists, pharmacists, nutritionists, social workers, etc.

46. Medical Homes: Affordable Care Act • Sec. 2703 established person-centered health home for State Medicaid and other programs • Individuals with chronic conditions • PTs not specifically named in statute but can partner with state entities to participate • Sec. 3502 provides grants to “eligible entities” to establish community-based health teams to support primary care providers in the creation of PCMHs

47. Medical Homes: Beyond the ACA • CMMI Challenge Grants • Up to $1 billion in grants for delivering better health, improved care and lower costs to people • CMMI FQHC Advanced Primary Care Practice • Private Partnerships • Geisinger Health System • Group Health, Seattle • TransforMED National Demonstration Project

48. Patient-Centered Medical Home Functions and Attributes Source: AHRQ Patient Centered Medical Home Resource Center

49. Harris County Hospital (Houston, TX)NCQA distinction as PCMH

50. Collaborative Care Resource Center • Evolving resource center designed for physical therapists to gain a better understanding of where PTs fit in integrated models of care • Practice Applications: discover lessons learned from colleagues currently engaging in new delivery models • Summary and analysis of federal rulemaking and how it impacts PT • http://www.apta.org/CollaborativeCare/ • Communities Discussion Board