Guest post by Ken Perez, vice president of healthcare policy, Omnicell.
In the wake of mixed initial results for the Pioneer ACO Model and Medicare Shared Savings Program (MSSP), this is the year for the Centers for Medicare & Medicaid Services (CMS) to take the feedback it has received and revamp its ACO programs.
The proposed rule for the 2015 Physician Fee Schedule (PFS), a 609-page document released on June 19, 2014, interestingly included the first installment of modifications to the ACO programs. The proposed rule devoted 52 pages to changes to the quality measures for the MSSP. Throughout the document, CMS emphasized its intent to align the numerous physician quality reporting programs, such as the Medicare EHR Incentive Program for Eligible Professionals and the MSSP, as much as possible, to reduce the administrative burden on the eligible professionals and group practices participating in these programs.
The final rule for the MSSP, issued in November 2011, presented 33 quality measures against which ACOs would be measured. These quality measures also apply to Pioneer ACOs. The measures pertain to four domains: patient/care giver experience, care coordination/patient safety, preventive health, and at-risk populations.
The proposed rule recommends the addition of the following 12 new measures:
1) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Stewardship of Patient Resources – This measure asks the patient whether the care team discussed prescription medicine costs with the patient.
2) Skilled Nursing Facility (SNF) 30-Day All-Cause Readmission Measure – This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a SNF within 30 days of discharge from a previous inpatient admission to a hospital, Critical Access Hospital or psychiatric hospital.
3) All-Cause Unplanned Admissions for Patients with Diabetes Mellitus (DM)
4) All-Cause Unplanned Admissions for Patients with Heart Failure (HF)
5) All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
6) Depression Remission at Twelve Months – Depression is a serious health condition that can reduce patient adherence to treatment for chronic conditions, and ACOs are in a position to address it.
7) Diabetes Measures for Foot Exam and Eye Exam – These exams help prevent diabetes-related foot amputations and blindness.
8) Coronary Artery Disease (CAD): Symptom Management – This new measure would add an assessment of patient activity level and management of angina, which are important clinical factors for Medicare beneficiaries with CAD.
9) Coronary Artery Disease (CAD): Beta Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF<40 percent) – This measure reflects the number of patients with CAD who have prior MI or LVEF<40 percent who are prescribed beta-blocker therapy.
10) Coronary Artery Disease (CAD): Antiplatelet Therapy – This measure is defined as the percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period that were prescribed aspirin or clopidogrel, reflecting current clinical guidelines.
11) Documentation of Current Medications in the Medical Record – This new measure promotes performing medication reconciliation at every office visit, not just immediately following a hospital discharge.
12) Percent of Primary Care Physicians (PCPs) who Successfully Meet Meaningful Use (MU) Requirements – This new measure is primarily an updated wording of an existing measure, shifting from “incentive payments” to “requirements,” reflecting the change in the MU program.
In addition, CMS proposes to retire the following eight current measures that have not kept up with clinical best practice, are redundant with other quality measures, or could be replaced by similar measures that are more appropriate for ACO quality reporting:
1) Medication Reconciliation after Discharge from an Inpatient Facility
2) Diabetes Composite measure: hemoglobin A1c control (<8 percent)
3) Diabetes Composite: Blood Pressure (<140/90)
4) Diabetes Composite: Tobacco Non-use
5) Diabetes Composite: Low Density Lipoprotein (<100)
6) Ischemic Vascular Disease: Complete Lipid Profile and LDL Control (<100 mg/dl)
7) Ischemic Vascular Disease: Use of Aspirin or another Antithrombotic
8) Coronary Artery Disease (CAD) Composite: Drug Therapy for Lowering LDL Cholesterol
In summary, CMS has proposed adding 12 new measures and retiring eight measures, resulting in a revised set of 37 measures to establish the quality performance standards that ACOs must meet to garner shared savings. Comments on the PFS proposed rule must be received by CMS by Sept. 2, 2014.
Additionally, on June 26, 2014, the White House’s Office of Management and Budget (OMB) received CMS’s proposed rule for the next version of the MSSP, which will be published in the Federal Register after OMB’s review. This proposed rule will presumably include changes to the financial terms of the MSSP and thus will impact the overall risk-reward proposition for ACOs. The changes will apply to current ACOs and approved ACO applicants that will start participating in the program on Jan. 1, 2016.
Regarding the Pioneer ACO Model, in December 2013, CMS’s Center for Medicare and Medicaid Innovation (CMMI) issued a request for information (RFI) seeking input on the Pioneer program and new ACO models. The RFI comment period ended March 1, 2014, and CMMI is expected to issue the details of the next generation of the Pioneer ACO Model later this year.
It will be interesting to see in these forthcoming communications whether CMS has enhanced or lessened the attractiveness of its ACO programs. Stay tuned!