Post on 21-Jun-2015
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FLAACOs Business Partners
Legal Considerations in Negotiating ACO Contracts
Broad and Cassel
Mike Segal
Phone: 305.373.9400Email:
msegal@broadandcassel.com
FLAACOs Business Partners
Background
The concept of "ACO's" introduced with the passage of the Affordable Care
Act CMS launches Pioneer ACO program and MSSP Triple Aim: lower costs, higher quality of care for defined population After ACO introduced, commercial payers got into the game
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Background
What do the new models look like? Leverage CMS model Shared savings for achieving and meeting cost and quality targets Move to downside risk only if confident cost and quality targets can be
satisfied All models rely on timely, actionable data
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Focus of Today's Discussion
Overview of emerging contract models for population health management Trends in data analytics Legal pitfalls with fraud and abuse waivers in commercial setting HIPAA considerations
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Refresher on CMS Models
MSSP and Pioneer ACO models Pioneer intended for more advanced ACOs
Both allow an ACO to take risk for defined population MSSP 2 Tracks: upside only or upside and downside Pioneer – 5 choices with opportunity to move to population based payments Fee for service remains intact (unless Pioneer with population based
payment)
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Refresher on CMS Models
Other features of programs Alignment – prospective vs retrospective Setting benchmark – look at historical claims Need to meet/exceed the benchmark AND meet minimum risk corridor to
share savings 33 quality measures – taken into account as well Move to downside risk only if confident cost and quality targets can be
satisfied
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Commercial Contract Considerations
Payers include insurance companies and large self-funded plans Since many use CMS model as starting point, make sure familiar with it Antitrust considerations (beyond scope of this discussion)
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Commercial Contract Considerations
A few key points to consider during negotiations (NOT all-inclusive) Number of covered lives – at least 5,000 Attribution – many use visit based (HMO can use member selection)
Visit based has pros and cons – if measured on quality need to make
sure you know who is in
Self-funded more likely to use PCP selection – ensures you capture
most/all of beneficiaries
True population encompasses everyone, not just sick
More opportunity to forge relationship with PCP and manage health
Payors attempting to forge more narrow networks
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Commercial Contract Considerations
Network Development for ACO Need primary care providers – how attribution is done Need high quality lower cost providers
Engage providers in developing commercial contract quality
measures
Ensures meaningful measures and uniformity across contracts
Incorporate as part of clinical protocols
Physician leader at negotiation table
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Commercial Contract Considerations
Data Considerations Ability to extract or receive feed to monitor quality is critical Receipt of claims feed from payer to validate targets with your actuary is
important Payer must also provide daily reports (admits, discharges, etc.) to manage
population – ACO needs to include in process
Patient Engagement Component of quality measure Patient portal development Engage caretakers as well in plan of care
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Commercial Contract Considerations
Validating Claims Data with your Actuary Evaluate current state of attributed population – 3 years of claims Validate medical cost target Advise re likelihood of success on quality measures – i.e., gateways to get $ Consider stop loss limits, high cost exclusions and amounts? Have static medical cost target vs reset every year to continue savings First dollar shared savings? Cap on savings and losses? Upside only for x years? Right to audit payer calculations of results
Shared Savings Contracts are Path Forward – Not Model of Sustainability
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Data Analytics/Population Health Management
Sources: electronic health records, state HIE, disease registries, claims Data vendor to churn claims for predictive modeling? Mechanism to tag high risk/high cost in EHR – vendor or payer? Physician input a must on meaningful dashboards, data, etc. Low risk – forge relationships to manage for long term Data drives action plans (high risk, medium risk, low risk, or other
stratification model chosen)
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Fraud and Abuse Waivers
5 Waivers Do not apply in commercial context Waivers do not override state law Shared savings distributions considerations Patient Incentive Considerations
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HIPAA Considerations
Disclosures without patient consent for treatment, payment, healthcare
operations Healthcare operations – includes population based activities to
Improve population health
Case management
Care coordination Many ACO activities fall under "healthcare operations"
BUT make sure boundaries are respected
ACO compliance officer is key
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Concluding Thoughts
Commercial shared savings and risk contracts are multiplying rapidly across
Florida and the country Plans will push moving rapidly to risk Do not trust plan data – must get it audited Right mix of physicians, with a robust PCP group, essential The next few years will be stressful, but exciting!
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Reach UsMike Segal, PartnerBroad and Cassel
Phone: 305.373.9400Email: msegal@broadandcassel.com Website: www.broadandcassel.com