ACO Proposed Rule Review: Part 5

 Patient–Centeredness Criteria

  •  Beneficiary Experience of Care Survey must be in place and there must be a description in the ACO’s application of how the ACO will use the results to improve care over time. CMS is proposing that ACOs be required to use the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, developed by AHRQ, along with an appropriate functional status survey module that may be incorporated in the CAHPS survey. (CMS solicits comment on requiring the CAHPS survey to be used in lieu of other tools of their own choosing (which would impede CMS’ ability to compare beneficiary experience across ACOs)–here is the link to information on CAHPS:
  • Patient Involvement in Governance—ACO must have a Medicare beneficiary on the governing board. The Medicare beneficiary or an immediate family member could not have a conflict of interest and they could not be an ACO provider/supplier within the ACO’s network. (CMS is soliciting comments on whether the requirement for beneficiary participation should include a minimum standard for such beneficiary participation on the ACO governing bodies (e.g., a minimum number of beneficiaries, or a minimum proportion of control over an ACO’s governing body).  Also, would: (1) a Medicare beneficiary advisory panel or committee be sufficient in and of itself in providing for appropriate patient participation in ACO governance; and (2) it be appropriate to require the establishment of patient advisory panels or committees in addition to patient representation on the ACO governing body).
  • Evaluation of Population Health Needs and Consideration of Diversity— In its application, the ACO must describe its process for evaluating the health needs of its Medicare population, and how it would consider diversity in its patient population, and how the ACO plans to address the needs of it populations.
  • Systems need to be in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations, including integration of community resources to address individual needs. 
    • The plan must be tailored to: (1) the beneficiary’s health and psychosocial needs; (2) account for beneficiary preferences and values; and (3) identify community and other resources (e.g., employers, commercial health plans, local businesses, State/local government agencies, local quality improvement organizations or collaborative such as Health Information Exchanges) to support the beneficiary in following the plan. 
    • The plan would be voluntary for the beneficiary, privacy protected, and would not be shared with Medicare or the ACO governing body (it would be solely used by the patient and ACO providers/suppliers for care coordination, although if the beneficiary consents, it could be shared with the caregiver, family and others involved in the beneficiary’s care).
    • The ACO would be required to have a process in place for developing, updating and as appropriate, sharing the beneficiary care plan with others involved in the beneficiary’s care, and providing it in a format that is actionable by the beneficiary.
    •   The ACO would be required to submit a description of its individualized care program, along with a sample care plan, and explain how this program is used to promote improved outcomes for, at a minimum, their high-risk and multiple chronic condition patients, as well as other target populations that would benefit from individualized care plans.
    •  The ACO would also be required to describe how it will partner with community stakeholders.  ACOs that have a stakeholder organization serving on their governing body would be deemed to have satisfied this requirement.
    • (CMS is requesting comments on the proposal requiring ACOs to demonstrate the use of individualized care plans for targeted beneficiary populations and is interested in hearing whether these requirement will create disincentives for participation among smaller entities).
  • A mechanism must be in place for the coordination of care (e.g., via use of enabling technologies or care coordinators), and the ACO must include description in its application for coordinating care. The ACO should have a process in place (or a clear path to develop such a process) to electronically exchange summary of care information when patients transition to another provider or setting of care, with within and outside the ACO, consistent with meaningful use.
  • The ACO must have a process in place for communicating clinical knowledge/evidence-based  medicine to beneficiaries in a way that is understandable to them and allows for beneficiary engagement and shared decision-making that takes into account the beneficiaries’ unique needs, preferences, values, and priorities. 
  • Written standards must be in place for beneficiary access and communication and a process in place for beneficiaries to access their medical record.
  • An ACO must have internal processes in place for measuring clinical or service performance by physicians across the practices, and using these results to improve care and service over time (note: the documents submitted to meet leadership and management criteria related to quality assurance and clinical integration program would satisfy this patient-centeredness criterion).

(CMS is soliciting comment on whether there are redundancies in the list of 8 above or other considerations that might justify narrowing the list.  Also, should patient centeredness criteria be sufficient to ensure that ACOs participating in the SSP meet the eligibility requirement to demonstrate patient centeredness or are their other considerations for meting this goal.  Alternatively, is the list of 8 too burdensome and would it create a disincentive to participate or make it difficult for small practices to participate in the program).

ACO Marketing Guidelines  

  • All ACO marketing materials, communications, and activities related to the ACO and its participation in the SSP such as mailings, telephone calls or community events, that are used to educate, solicit, notify, or contact Medicare beneficiaries or providers/suppliers regarding the ACO and its participation in the SSP, be approved by CMS before use to protect beneficiaries and to ensure that they are not confusing or misleading.  This requirement would also apply to any materials or activities used by ACO participants or ACO providers/suppliers on behalf of the ACO to communicate about the ACO’s participation. 
  • Approval would be required for revisions as well. 
  • Failure to comply with these requirements would result in the ACO being placed under a corrective action plan or terminated at CMS’ discretion.  The dubious “rationale” is the not checking in with CMS would demonstrate that the ACO does not meet the patient-centeredness criteria (sorry, couldn’t refrain from making editorial comments).

 Program Integrity Requirements

  • Compliance Plans—to address how the ACO will comply with applicable legal requirements, and should include: a designated compliance official or individual who is not legal counsel to the ACO and who reports directly to the ACO’s governing body; mechanisms for identifying and addressing compliance problems related to the ACO’s operations and performance; a method for employees or contractors of the ACO or ACO providers/suppliers to report suspected problems related to the ACO; compliance training of the ACO’s employees and contractors; and a requirement to report suspected violations of law to an appropriate law enforcement agency.  ACOs can build on existing compliance programs to meet this requirement.
  •  Compliance with Program Requirements:
    • All contracts or arrangements between or among the ACO, its ACO participants and ACO providers/suppliers, and other entities furnishing services related to ACO activities require compliance with the obligations under the 3-year agreement, including document retention and access requirements.
    • An authorized representative –specifically an executive who has the ability to legally bind the ACO—must certify the accuracy, completeness, and truthfulness of information contained in its SSP application, 3-year agreement, and submissions of quality data and other information.  The certification must be made at the time the application, agreement, and information is submitted.
    • As a condition of receiving a shared savings payment, an authorized representative with authority to legally bind the ACO must make a written request to us for payment of the shared savings in a document that certifies the ACO’s compliance with program requirements as well as the accuracy, completeness, and truthfulness of any information submitted by the ACO, the ACO participants, or the ACO providers/suppliers to CMS, including any quality data or other information or data relied upon by CMS in determining the ACO’s eligibility for, and the amount of, a shared savings payment or the amount owed by the ACO to CMS.
    • If data are generated by ACO participants or another individual or entity, or a contractor, or a subcontractor of the ACO or the ACO participants, such ACO participant, individual, entity, contractor, or subcontractor must similarly certify the accuracy, completeness, and truthfulness of the data and provide the government with access to data   for audit, evaluation, and inspection.
  • Conflicts of Interest—the ACO governing body must have a conflicts of interest policy that applies to members of the governing body.  Such policy must require members of the governing body to disclose relevant financial interests.  The policy must also provide a procedure for the ACO to determine whether a conflict of interest exists and set forth a process to address any conflicts that arise.  The policy must address remedial action for members of the governing body that fail to comply with the policy.  (CMS solicits comments on this proposal, including the scope and content of such a policy).
  • Screening of ACO Applicants—CMS is considering screening ACOs during the application process with regard to their (should this be their ACO participants and ACO providers’/suppliers’) history, including any history of program exclusions or other sanctions and affiliations with individuals or entities that have a history of program integrity issues.  ACO’s whose screening reveals a history of program integrity issues and/or affiliations with individuals or entities that have a history of program integrity issues may be subject to rejection of their SSP application or the imposition of additional safeguards or assurances against program integrity risks.  (CMS solicits comments on the nature and extent of such screening and the screening results that would justify rejection of an application or increased scrutiny).
  •  Prohibition on Certain Required Referrals and Cost-shifting—CMS is considering prohibiting ACOs and their ACO participants from conditioning participation in the ACO on referrals of Federal health care program business that the ACO or its ACO participants know or should know is being provided to beneficiaries who are not assigned to the ACO. (Comments on this would be appropriate).

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