ACOs, Risk Adjustment and Balance-Billing Medicare

February 14, 2012 | Filed under: MANAGED CARE | Posted by: Angela Atkinson

ACOs offer Doctors and Hospitals Financial Incentives to Provide Good Quality Care.
<ol>
<li>
Our dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives.</li>
<li>
What’s more, if ACOs foster more market concentration among providers, they have the potential to shift costs onto private insurers.</li>
</ol>

Exactly how ACOs would work in practice remains to be seen, though that hasn't stopped the health care industry from embarking on a frenzied quest to create them as quickly as possible.

With this being the case (and it most certainly is), ACOs are complex and one could easily suffer from too much change, too fast.
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Start slow, proceed with caution, phased approach, and accept the risk you can, avoiding the risk you can not manage.
<ol>
<li>
Prepare a business plan.</li>
<li>
What is the opportunity/strategy?</li>
<li>
What physicians/hospitals and others will be inside the ACO?</li>
<li>
How will the ACO coordinate care, deliver quality, achieve savings?</li>
<li>
What staff/IT systems will be required?</li>
<li>
Project a 3-5 year budget</li>
<li>
Project various revenue models.</li>
<li>
Can it work?</li>
</ol>

In the new law, ACOs would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.

This is going to be problematic for rural areas, very problematic.

ACOs would make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures.

The Physician Incentive Payment Prohibition (CMP Law) will need to be considered here.

A hospital may not knowingly make a payment, directly or indirectly, to a physician as an inducement to reduce or limit services provided with respect to individuals who are entitled to benefits under Medicare part A or part B or to medical assistance under a State plan, and are under the direct care of the physician; applies only in the fee-for- service context.

Some Considerations
<ol>
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Stark Law – Certain exceptions apply to MCO’s and will likely apply to many ACOs.</li>
<li>
Anti-kickback Statute – I don’t think we’ll see any “safe harbors” here.</li>
<li>
Antitrust – How will the internal structure of provider network within the ACO be organized?</li>
</ol>

The FTC will want to ensure that the ACO does not facilitate unlawful agreements between competitors.

Some Contract Considerations

I would imagine that the legal structure of ACOs will be articulated in contracts between providers.
<ol>
<li>
Network Relationships- Ensure that providers in ACO network are responsible for coordinating all aspects of patient care.</li>
<li>
Economic Relationships- Determine how shared savings will be distributed among physician and other provider members of the ACO.</li>
<li>
I would think that existing managed care contracts may be used as models for ACO relationships.</li>
<li>
Contracts- must be carefully drafted to ensure compliance with the Stark law, the anti-kickback laws, the CMP law and other Federal and State fraud and abuse laws.</li>
</ol>

Some Issues
<ol>
<li>
ACO’s focus – Medicare patient’s only/commercial only/mixed payer? </li>
<li>
Patients will be able to leave the ACO, unlike the HMO.</li>
<li>
What functions will be delegated to the ACO Board?</li>
<li>
How will governance/leadership be structured on the physician side?</li>
<li>
Who will staff the ACO?</li>
<li>
How to pick partners in the ACO?</li>
</ol>

Risk Adjustment

Introduction

People eligible for Medicare have been able to choose between:
<ol>
<li>
The regular fee-for-service plan, under which the federal government pays a set fee to health care providers for each service provided, and</li>
<li>
Medicare Advantage (MA), whereby the government pays private health plans a fee for each individual they enroll.</li>
</ol>

Paying the same amount for every person enrolled in a health plan encourages plans to enroll low-cost people and to avoid high-cost ones. Because of this, the federal government historically overpaid for MA enrollees relative to their costs in traditional Medicare.

Prior to risk adjustment, insurers simply had an incentive to enroll individuals with low costs. After risk adjustment, insurers instead had an incentive to enroll individuals with low costs conditional on their medical conditions.

“Risk Adjustment”contains revisions to the Social Security Act, including a new clause that mandates:
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Evaluation of the Centers for Medicare & Medicaid Services (CMS) risk adjustment system used to account for medical expenditures and care coordination costs for specified subsets of beneficiaries.</li>
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Publication of that evaluation and any changes occurring as a result of the evaluation.</li>
</ol>

Major Sections
<ol>
<li>
Use of risk adjustment within a health insurance market.</li>
<li>
Evaluation of the CMS-HCC model, with an:</li>
</ol>

Ø  Evaluation of the predictive accuracy of the model for individuals and groups
<ol>
<li>
Analysis to determine if there are integral differences between</li>
</ol>

Ø  Individuals in MA Chronic Condition Special Needs Plans (C-SNPs) and

Ø  Fee-for-service (FFS) beneficiaries with similar diagnostic profiles

Risk Adjustment
<ol>
<li>
Method of adjusting capitation payments to health plans.</li>
<li>
Either higher or lower, to account for the differences in expected health costs of individuals.</li>
</ol>

Insurers Revenue Needs
<ol>
<li>
Trends in medical expenditures.</li>
<li>
Anticipated enrollment, to:</li>
</ol>

Ø  Determine how much to vary the premium charged to individuals or small groups of enrollees.

Risk Adjustment Models used in the MA program
<ol>
<li>
Diagnoses and demographic information are used to set each enrollee’s monthly capitation rate.</li>
</ol>

Ø  Individual level – predicted medical costs can be lower or higher than actual medical costs.

Ø  Group level – below-average predicted costs balance out above-average predicted costs.

Health Insurance
<ol>
<li>
Form of risk management primarily used to hedge against the risk of a contingent, uncertain loss.</li>
<li>
Equitable transfer of the risk of a loss, from one entity to another, in exchange for payment.</li>
</ol>

Medicare
<ol>
<li>
~47 million beneficiaries.</li>
<li>
~14 million of Medicare beneficiaries receive their Medicare health benefits through private health care plans, a program known as Medicare Advantage (MA).</li>
<li>
Medicare pays these participating health plans a monthly capitation rate to provide health care services for their enrollees.</li>
</ol>

Risk Adjustment Factors
<ol>
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Medicare beneficiaries vary greatly in terms of their health status, which in turn affects their utilization and costs.</li>
<li>
By risk adjusting the payments to MA plans—beneficiaries with lower-than-average predicted costs have their payments decreased incrementally based on their risk profile.</li>
<li>
Beneficiaries with higher-than-average predicted costs have their payments increased incrementally based on their risk profile.</li>
</ol>

History

Historically, capitation payments to Medicare managed care plans were linked to FFS expenditures by geographic area.

Principles for Risk Adjustment Model Development
<ol>
<li>
The CMS-HCC risk adjustment model is prospective – it uses demographic information and a profile of major medical conditions in the base year to predict Medicare expenditures in the next year.</li>
<li>
It is calibrated on the FFS population because this population, unlike the MA population, submits complete Medicare claims data, including both diagnoses and expenditures.</li>
</ol>

Diagnostic Classification System

Used to determine which diagnosis codes should be included, how they should be grouped, and how the diagnostic groupings should interact for risk adjustment purposes – 10 principles:
<ol>
<li>
Diagnostic categories should be clinically meaningful.</li>
<li>
Diagnostic categories should predict medical expenditures.</li>
<li>
Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures.</li>
<li>
In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate.</li>
<li>
The diagnostic classification should encourage specific coding.</li>
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The diagnostic classification should not reward coding proliferation.</li>
<li>
Providers should not be penalized for recording additional diagnoses (monotonicity).</li>
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The classification system should be internally consistent (transitive).</li>
<li>
The diagnostic classification should assign all ICD-9-CM codes (exhaustive classification).</li>
<li>
Discretionary diagnostic categories should be excluded from payment models.</li>
</ol>

Hierarchies

Hierarchies are imposed among related CCs (condition category), so that a person is coded for only the most severe manifestation among related diseases.

Challenge

1.     The challenge is to help physicians who have leaned to chart and code for Medicare fee for service which is procedure code driven, to also:

2.     Recognize the need to document the underlying chronic disease which may be the cause of the acute episode or the chief complaint for the visit.

Problematic
<ol>
<li>
The formula systematically over-predicts costs for those with below average costs, and systematically under-predicts costs for those with above average costs.</li>
<li>
Fragmentation and competition among plans.</li>
<li>
Capitation payments to doctors as well as groups of doctors.</li>
<li>
Problem does not exist with fee-for-service (time, skill, and effort w/o risk adjustments).</li>
<li>
Doctors acting in the actuarial role of insurance companies</li>
</ol>

Risk Adjustment Models
<ol>
<li>
All risk adjustment modeling tools follow the same process – they classify and group medical codes into predetermined classifications, generate relative risk scores for individuals measured, and provide output.</li>
</ol>

Ø  ~16,000 ICD-9-CM codes in the code set

Ø  ~68,000 ICD-10-CM codes in the code set.

From Risk Scores to Fund Transfer

Risk scores can be aggregated to compare group-level differences in healthcare cost and utilization.

There are two types of risk-adjusted payment arrangements—Prospective and Retrospective.
<ol>
<li>
In Prospective Risk Adjustment, patients’ historical claims are used to generate the relative risk scores and set annual budgets for the group for the upcoming year.</li>
</ol>

Ø  The risk scores and budget may be updated on a quarterly basis or another schedule throughout the year.

Ø  Final budget can take additional months to settle, allowing for claims to run out and membership information to be finalized.
<ol>
<li>
In Retrospective Risk Adjustment, a provider group can either be paid on fee-for-service or on a fixed capitation fee to begin with.</li>
</ol>

Ø  Risk scores are based on the current year’s experience instead of historical claims.

Ø  For this reason, final risk scores will be determined a few months after year-end, to allow for claim run-out and membership true-up.

Risk adjustment is primarily centered on accountable care organization (ACO) and patient-centered medical home (PCMH) programs.

Balance-Billing Medicare

We don’t hear much about this but I think it is very worthy. I also believe it could significantly impact business decisions.

A bill introduced in the House on May 4, 2011 would let physicians "balance-bill" Medicare patients for the amount above Medicare's allowable charge, and still remain in the program.

The legislation, titled the Medicare Patient Empowerment Act, would allow physicians to privately contract with patients on what they will pay for medical services. Right now, the only way physicians can enter into these agreements is if they drop out of Medicare altogether.

Medicare currently allows balance-billing for physicians who have elected to be "non-participants". Physicians are still able to bill Medicare for their services as non-participants.

The majority of physicians elect "participant" status in Medicare; by doing so, they accept Medicare’s allowable as payment in full, and can not balance-bill the patient.

For example, the nationwide allowable for a 99213 is $68.97. Medicare's 80% share is $55.18; the patient's share is $13.79.

Physicians who choose to be non-participating can take assignment on Medicare claims on a case-by-case basis. If they take assignment, they can charge only 95% of the Medicare allowable; for a 99213 that would be $65.52.

If they decline to take assignment, non-participants are free to charge the patient up to 115% of the Medicare allowable, what Medicare calls the "limiting charge."

In this scenario, the physician still submits a claim, but Medicare sends a check for its share of the discounted allowable not to the physician, but to the patient. The physician must collect the full amount of his or her charge from the patient.

In the case of a 99213, a non-participating physician who does not take assignment could charge the patient a maximum of $75.35, which is 115% of $65.52. Medicare's share would be 80% of $65.52, or $52.42; the patient's 20% co-insurance would be $13.10; and the remaining $7.83 is a balance-bill amount also owed by the patient.

Physicians who want to avoid the limiting charge and other Medicare restrictions can opt out of Medicare entirely and privately contract with patients to set fees at whatever level is agreed upon.

A physician who opts out of Medicare must stay out for 2 years before reentering it. During that time, he or she cannot submit a claim to Medicare for services rendered. Patients who contract with such physicians forgo any Medicare reimbursement. The financial transaction is entirely between physician and patient.

The private-contracting legislation in the House would eliminate these restrictions. It would make balance-billing available to participating and non-participating physicians alike. In addition, there would be no upper limit to the charge that patient and physician agree on.

The fee for a 99213 office visit could be $100; Medicare's share would be 80% of the full Medicare allowable, or $55.18, regardless of whether the physician is participating or non-participating.

Under the bill, the Medicare patient could pay the full $100 directly to the physician and then file a claim with Medicare to get reimbursed for the Medicare allowable. The contract also could permit the physician to file this claim and collect the allowable directly from Medicare. No matter who files, the patient is responsible for an amount above his or her usual 20% co-insurance.

The Medicare Patient Empowerment Act would permit physicians to keep either their participating or non-participating status in Medicare with patients who do not privately contract with them. Likewise, patients who sign these contracts do not forfeit any of their Medicare benefits.

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