NWX-HHS-AOA-1 (US)

Moderator: Lauren Solkowski

10-13-15/1:00 pm CT

Confirmation # 4910147

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NWX-HHS-AOA-1 (US)

Moderator: Lauren Solkowski

October 13, 2015

1:00 pm CT

Coordinator: Welcome and thank you for standing by. All participants will be on a listenonly mode for the duration of today’s conference until the end of the 

presentation when we will be conducting a question and answer session.

Today’s call is being recorded. If anyone has any objections you may 

disconnect at this time.

I would now like to turn the conference over to Lauren Solkowski. Thank you. 

You may begin.

Lauren Solkowski: Great thank you. And good afternoon and thank you everyone for joining 

us today for the Administration for Community Living’s Business Acumen 

Webinar entitled Community Based Organization Impact on Health System 

Quality and Performance Measures.

Today’s Webinar is the third of three part series focusing on health system 

quality measures. And the Webinar for today will focus on ACO or 

Accountable Care Organization quality measures.

This is Lauren Solkowski with ACL and I will be facilitating our Webinar.
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So for today we have invited Tim McNeil and he’s going to be presenting on 

the ACO quality measures.

Before we start with this presentation I have a few housekeeping 

announcements. So the first is if you have not done so please use the link that 

was included in the calendar appointment to get onto WebEx so that you can 

follow along with the slides but also since you can ask your questions when 

you have them through chat.

If you don’t have access to the link that was emailed you can also go to 

www.webex.com, click on the Attend a Meeting button that’s at the top of the 

page and then enter the meeting number.

Today’s meeting number is 669853365. Again that meeting number is 

669853365. If you have problems getting onto WebEx please call technical 

support number. That phone number is 1-866-229-3239. Again it’s 1-866-

229-3239.

As our operator has mentioned all of our participants are in a listen-only mode 

however we do welcome your questions throughout the course of the 

Webinar.

There are two ways that you can ask your questions. The first is through the 

Web using the chat function in WebEx. So you can enter your questions and 

we will sort through them and answer them once Tim has completed his 

presentation.
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In addition to asking your questions through the chat function again after Tim 

wraps up we will - you’ll have a chance to ask your question through the 

phone line.

So when that time comes the operator will give us instructions as to how to 

queue up to ask your question.

If there are any questions that we aren’t able to answer during the webinar we 

will be sure to follow up with you to get them answered.

If you think of any questions after the Webinar please feel free to email them 

to me at lauren.solkowsk@acl.hhs.gov. I have entered my email address in the 

chat box on the Webinar on the right-hand side of the screen.

Also as the operator had mentioned we are recording the Webinar. We will be 

posting the recording the slides and a transcript of the Webinar online for your 

reference.

Okay so with that I would like to introduce and welcome our speaker for 

today Tim McNeil. Tim is an independent healthcare consultant specializing 

in health program development and sustainability.

Tim thank you again for being with us today and I will turn the call over to 

you.

Tim McNeill: Great. Thank you so much. So Lauren are the slides up because I don’t have 

the slides on my screen?

Lauren Solkowski: Okay. I see the slides you don’t see. Let’s see at the top there’s like three 

tabs. It says Quickstart Event and so and then a tab for your slides?
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Oh someone else just said that they don’t - not seen the slides. Okay, my 

apologies. Let me try this one more time. I’m going to close this out and 

reload them, just give - everyone give me one second.

Okay they should - can you see them now?

Tim McNeill: I see them now. I sure do.

Lauren Solkowski: Perfect great. Okay you’re welcome to begin.

Tim McNeill: Great.

Lauren Solkowski: Sorry about that.

Tim McNeill: Okay thank you. So this is the third part in the Quality Series. Today we’ll 

take a deep dive into the accountable care organizations.

Next slide, so we’re going to have a little conversation about macro and its 

impact on ACOs and what I foresee what will likely cause a growth in ACO 

activity in your local markets.

As - then we will look at the ACO quality measures. I will highlight some 

particular points of pain as it relates to ACOs and potential next steps.

Next slide, so the - as was kind of been the underlying theme throughout all of 

these quality presentations there is robust changes in the healthcare landscape.

And a lot of that was spurred by the Affordable Care Act.
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And what’s really moving things now is MACRA which is the Medicare 

Access and CHIP Reauthorization Act where there’s increased emphasis on 

position participation and what is termed alternative payment models.

There are a couple types of alternative payment models that are specifically 

spelled out in the MACRA legislation. And one is ACOs or Accountable Care 

Organizations and bundled payment.

Next slide, so as there was a significant push for greater adoption in physician 

and hospital participation in APMs or Alternative Payment Models.

And that was really kicked off by an event that occurred on January 26 in

2015 where HHS Secretary Sylvia Burwell announced measurable goals and a 

timeline to move the Medicare program towards paying for quality rather than 

paying for quantity.

So essentially we’re moving the entire health care system to one where we 

pay for outcomes instead of just paying for units of service.

And those goals outlined in this press release where the link that is below if 

you’d like to read the actual transcript of the press release is that 30% of all 

fee for service Medicare payments will be through an alternative payment 

model and 50% of those payments will be through these models by 2018. The 

30% was by 2016.

And so CMS or excuse me, HHS set a specific target where we would move 

to the payment system going to these alternative payment models and ACO’s 

is definitely one of those models that meets the mark.
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Next slide, so the - one of the early impacts of MACRA or the Doc Fix bill 

which many refer to is it repeals the SGR methodology which was the 

sustainable growth rate formula which essentially reset the payment system to 

adjust all Medicare payments down to save costs or save expenditures and to 

preserve the Medicare Trust Fund.

The macro legislation essentially sunsets the - this current physician payment 

adjustments which included PQRS or the Physician Quality Reporting System 

the value-based payment modifier for physicians and the EHR Incentive 

program.

And so providers that scored poorly on those markers have the potential of 

losing accumulative amount of 8% of their Medicare payments by 2018.

And it - the macro legislation replaces all of those things with what’s called a 

Merit-based Incentive Payment System or MIPS by 2019.

So we will continue down the path of maintaining these existing physician 

payment adjustments based on quality and meeting specific requirements and 

begin ramping up to a merit based incentive payment model by 2018.

And I want to emphasize that just like with the hospital readmission program 

a facility or physician is assessed based on their level of meeting certain 

quality benchmarks during a particular calendar year.

And then any potential penalty or increases in revenue based on worst or 

improved performance is applied to the following year.

So when we talk about maximum penalties of 8% by 2018 that means that 

they’re going to be assessed in 2017 which means they need to get things in 
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place by 2016 to meet the markers by 2017 and then they will - that penalty or 

lack thereof will be assessed by 2018.

And then the merit-based payment incentive payment system also will be 

assessing physician quality in 2017 and 2018 to apply the incentive model by 

2019.

So I wanted - the reason I highlight that is you may look at those and say well 

the, you know, 2018, 2019 those are eons away and no one’s really paying 

attention to that now.

Or I rest assured that all of these physician advocacy groups are having 

continued presentations and Webinars to help provider begin getting prepared 

for these models now. Because as I said they’re going to rate them in advance 

of the implementation and then their score is what the score is and the penalty 

or lack thereof will be assessed going forward.

Next slide, an additional impact of macro is that eligible providers will be 

subject to an initial 4% payment adjustment. And this is again is in 2019 

which grows to 9% by 2022 and then continues it plateaus at potential 9%.

So this merit-based incentive payment system is completely based on provider 

quality. So you see we are getting very serious about adjusting provider 

payments based on quality and outcomes.

And we’re really highlighting providers because it’s not just physicians. The 

eligible providers includes nurse practitioners, physicians assistants so all of 

these providers in group practices and all the providers in those group 

practices are going to be impacted by these payment adjustments that are well 

underway.
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Now eligible providers -- and this is a key point -- eligible providers that meet 

the alternative payment methodology threshold are exempt and receive a lump 

sum incentive payment instead of being subject to a potential MIPS penalty.

So if we - if I am a group practice, I’m a hospital and the majority of the 

providers in my group are participating in ACOs and bundled payment then 

we are exempt from this potential 4% to 9% adjustment up or down in our 

Medicare payment and actually we get a lump sum incentive payment at the 

beginning of the year and we’re not subject to the potential penalty all by 

being a participant in Alternative Payment Models like ACOs and bundle 

payment.

Next slide, so what is that lump sum? So these eligible providers that meet the 

minimal threshold will receive a 5% lump sum incentive payment based on 

the estimated aggregate of Part B covered professional services for the 

preceding year. So let’s look at 2019.

So in 2019 an eligible provider, a multi-specialty group practice, if they have 

25% of their payments through alternative payment models like ACOs and 

bundle payment then at the beginning of 2019 they’re going to get a 5% lump 

sum incentive payment that is estimated based on the aggregate of all of their 

services for the year in one big check at the beginning of the year as incentive 

for them to continue to be in these alternative payment models.

So you see that there’s a big carrot at the end of the rainbow there for a 

provider to be in these models. And it, you know, it equates to real cash in 

real-time.
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By 2021, 2022 eligible providers must have 50% of their payments through 

alternative payment models in order to get the 5% lump sum incentive 

payment at the beginning of the year.

So if you’re in a market where there was little activity of ACOs and a few 

participants in bundled payment just wait until these things begin to take hold.

And this type of hard cash incentive on the front end in addition to being 

exempt from potential penalties on the back end all will - are seen as a way to 

incentivize providers to robustly participate in alternative payment models.

And the two that are most quoted includes ACOs and bundled payments.

Next slide, so the alternative payment model of accountable care 

organizations what are those?

So CMS defines accountable care organizations as groups of doctors, 

hospitals and other healthcare providers who come together voluntarily to give 

coordinated care to Medicare beneficiaries.

So I want to highlight that the target population for ACO participation are 

Medicare eligible beneficiaries that are in original Medicare fee for service 

Medicare.

If a consumer elects to be in Medicare Advantage then they are opting out of 

participation in an accountable care organization because Medicare Advantage 

participation is it excludes a person from being in an ACO. It is only for 

original Medicare.

So that fee for service population includes traditional original Medicare. It 

includes dual eligibles that have Medicare as their primary payer all that as 
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well as end-stage renal disease consumers that have Medicare as their primary 

insurer. All of those consumers would be part of an accountable care 

organization based on an attribution methodology that I will explain next.

Next slide, so the ACO goal is to provide coordinated care to the attributed set 

of Medicare fee for service beneficiaries.

They really strive to improve health outcomes and reduce healthcare 

expenditures. And by if they are able to successfully improve outcomes and 

reduce expenditures then they are eligible for a share in the savings that they 

create.

Next slide, so when the ACO succeeds in improving these health outcomes 

they get a share in the savings. Prior to ACOs or accountable care 

organizations there was not a mechanism to for CMS to share savings with 

providers.

So if I was a provider at one hospital I had excellent outcomes and I 

significantly because of the excellent outcomes there was reduced cost to the 

taxpayer, reduced expenditures of Medicare I got the exact same payment 

amount as the provider across town that had horrible outcomes and had 

tremendously high expenditures with lots of complications.

Actually it was almost a reverse incentive model. The provider that had lots of 

complications did more and more procedures to correct those complications.

And they actually got more in the way of financial compensation purely on 

the fact that it was a - we were - are in a traditional fee for service model so 

the more services you provide the more fees you pay.
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And so the ACO provides a mechanism for providers that have excellent 

outcomes and reduced cost of care and reduced Medicare expenditures to 

receive a percentage of the savings they create.

Next slide, so the - there three types of Medicare ACO programs currently.

One is the Medicare Shared Savings program. This is by far the most 

common. There’s hundreds and hundreds of participants in the Medicare 

Shared Savings program across the country.

There’s the Pioneer ACO model. There are only 19 remaining participants in 

the Pioneer ACO model. And at this time CMS has stated they don’t foresee 

having another round of Pioneer applicants.

And most recently there’s been an open application for the next generation 

ACO models. Those will be awarded. They’re expected to begin January 1 of 

2016. And the next generation ACOs are almost a full risk model ACO.

So we’re waiting to see which sites are selected to be part of the next 

generation ACOs.

I will - just one point of clarification a site that was currently operating as a 

Medicare Shared Savings program ACO or a Pioneer ACO was eligible to 

apply to transition over to next generation ACO status this round. So we may 

see some movement where there were existing Pioneers or existing Medicare 

Shared Savings programs ACO’ that applied and may be selected to be a next 

generation ACO. We’ll find out when the awardees are noticed - are publicly 

notified and submitted on the CMS Web site.

Next slide, so the attribution process so what happens when a group of 

providers decide to go into the ACO program?
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The MSSP or the Medicare Shared Savings Program ACO applications the 

application window opens each July. In - and that process entails all of the 

providers that are wishing to be part of that ACO will submit their tax ID 

number two as part of the group to CMS or the tent.

And then there’s a three year look back of all beneficiaries that were served by 

the primary care providers that were linked to those tax ID numbers prior to 

their request to start in the ACO program.

Consumers are then attributed to a provider based on which provider paid,

received the majority of paid primary care services during that three year look 

back period and so and it is essentially a one to one count of paid claims.

So if a consumer a good example are the snowbirds. So a snowbird lives in 

New York for part of the year and then lives in Florida for a part of the year 

they may have a doctor in Florida and a doctor in New York.

If either one of those doctors chooses to participate in the ACO program CMS 

would look at the tax ID numbers of both of those providers and then they 

would do a count to see which provider had the preponderance of Medicare 

paid claims for that consumer and which - and there’s a one to one count 

which everyone had the majority of paid claims that consumer will be 

attributed to that provider.

And so then that consumer is attributed to the ACO for which the provider had 

the most paid claims during the three year look back period.
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Next slide, so hospitals and specialists. Since the ACO attribution process is 

tied to the primary care provider consumers are attributed linked to where they 

got the most primary care services.

And so therefore primary care providers can only participate in one ACO. 

They can change ACO so they have the option to leave one ACO and join 

another but they can only - the primary care provider can only participate in 

one ACO at a time.

Specialists generally do not attribute beneficiaries unless a beneficiary had no 

primary care claims during the three year look back period prior to the ACO 

start.

Hospitals also don’t attribute beneficiaries because they don’t - hospitals don’t 

provide primary care. The caveat is when a hospital owns a primary care 

practice generally that primary care practice operates under a different tax ID 

number than the hospital and it’s the primary care practice that goes into the -

that attributes consumers or beneficiaries to the ACO. The hospital tax ID 

number generally doesn’t attribute consumers to the ACO.

Now one thing that is also important to note just like the primary care provider 

can only participate in one a specialist can participate in multiple ACOs and 

hospitals can participate in multiple ACOs.

One thing that also a requirement when ACOs apply to be part of the ACO 

program they have to submit to CMS information about how they plan to selfregulate good participants in the ACO to assure that all providers within the 

ACO are meeting the standards for quality and costs that are set forth by the 

program.
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And the ACO has to provide to CMS a method by which they allow new 

providers to come into their ACO. They also have to provide information 

about how they remove providers from the ACO that do not meet benchmark 

qualities for standards.

So many of you as you think about how you’re establishing your networks --

and that’s one thing that we’ve talked about multiple times -- is setting 

performance and quality standards.

The ACOs all had to do that as well. In addition to that they had to provide 

information to CMS about how they will remove a provider that does not meet 

the minimum metrics for quality standards that the ACO sets and they have to 

have a process by which they remove providers.

Next slide, so MSSP or Medicare shared saving program ACOs can earn up to 

60% of the savings they create depending on how they perform on 33 quality 

measures. We’re going to go in-depth on these 32 quality measures.

For the initial three to five year period MMS ACO MSSP ACOs are not 

required to take risks but then after that they have to begin taking risks to stay 

into the program.

Pioneer ACOs can earn up to 75% of the savings they create so you see they 

are able to earn a considerable more of the savings that they’re able to create.

But Pioneer ACOs almost take risks for the losses that are also incurred.

So the next generation ACOs they have to take risks as soon as they begin the 

program. The Pioneer ACOs are all at a period, a phase where they have to 

take this now. And MSSP ACOs if they request the maximum percentage of 

savings at 60% they have to take some risks to get that level.
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If they choose a no risk one-sided upside only model then they can only earn 

up to 50% of the savings they create.

Next slide, so what makes up the cost analysis? When we talk about the 

savings that are created as I said there’s a three year look back period to 

identify which consumers are attributed to the ACO. And then they start in the 

ACO program January of the - of that proceeding year, the following year.

So that three-year look back period looks at all the costs that those consumers 

had to establish a baseline. And it’s a three year weighted average to establish 

what the baseline costs are.

And so the ACO knows January when they start the benchmark cost for their 

population and what’s included in those costs are only Part A and Part B 

expenditures.

What’s excluded from those benchmark costs as well as the reconciliation or

comparison of their participants to looking for potential savings what’s 

excluded are all Part B costs. So that’s the prescription costs. Medicaid costs 

are not included because it’s only Medicare Part A and Part B Medicaid long

term service support, Medicaid home community-based services.

None of these things are included in either the benchmark costs nor are they 

included in the savings calculations for shared savings program ACOs. Only -

ACOs only assess Part A and Part B expenditures. And that’s important and 

I’ll go into that here soon.

Next slide, so Part A benefits just as a recap Part A benefits cover inpatient 

hospital care, skilled nursing care, home health and hospice.
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And the two biggest cost drivers of Part A obviously is inpatient hospital care 

and skilled nursing facility care.

And there’s a particular emphasis on as you can imagine readmissions, what’s 

called ambulatory sensitive admissions or unnecessary admissions, skilled 

nursing facility, primary admissions and readmissions. Because those are so 

expensive so there’s a great emphasis on those.

Next slide, Part B benefits cover outpatient services, preventative health,

doctor visits and so forth. So generally Part B services are much less costly 

and the preventive health services hopefully will drive down the utilization of 

the Part A services which should only occur when there’s a complication.

Next slide, so Medicaid, the reason I highlight Medicaid is because when you 

have a dual and a dual has primary payer be a Medicare with Medicaid be a

secondary payer those tools would be attributed to an ACO when the ACO 

providers provided the primary - the bulk of the primary care for those duals 

that remain in original Medicare as a start.

So when CMS gives the benchmark data to ACOs they generally give them 

their benchmark data in three categories.

They give them their total benchmark cost and quality for the non-dual 

eligible population.

Then they give them the second report that singles out the dual eligibles. Then 

they give them a third statement that singles out the end-stage renal disease.
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And the reason that the duals and the end state renal disease populations are 

highlighted because for the vast majority of ACOs the two groups that have 

the greatest per capita expenditures of Part A and Part B services are duals and 

end-stage renal disease.

And so that - there’s lot of emphasis placed on those two population groups 

because from a shared savings perspective if you’re looking to bring down 

costs and improve quality you likely look at the groups that have the highest 

per capita cost.

And it’s - for most ACOs it is the duals and end stage renal disease 

population. And CMS give those reports separately so their groups can very 

quickly begin stratifying their population health methodology to address the 

needs of those groups. Because the biggest pot of money for potential savings 

are held in those groups.

Next slide, so duals, 20% of Medicare beneficiaries are dual eligibles. Duals 

have as I said, significantly higher per capita expense. So a MedPAC report 

June of 2013 on Page 153 if you just Google MedPAC Report to Congress 

June 2013 you’ll pull up this report.

And on Page 153 they specifically outlined dual eligibles and fee for service.

Their per capita spending was $15,743 compared to 8081 for non-duals.

So as you see the per capita spending difference is tremendous. And if I am -

if I’m running an ACO and I have limited resources because I can’t have a 

private duty case manager for every consumer if you look at an ACO like BJC 

Healthcare in St. Louis that’s working with one of the business acumen 

partners part of the St. Louis collaborative, they have 50,000 beneficiaries in 
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their ACO. They could not possibly have a private duty case manager for 

50,000 consumers.

But if so if knowing that they have limited resources if they were going to 

target their care management services to the group that potentially give them 

the greatest earnings in a shared savings model it would be the dual eligibles 

because the per capita spending is so tremendously higher.

And if there’s any ACO or if you’re working with any hospital ACO they had 

if they question that or if they felt as though that was not true then, you know, 

definitely provide them this information with the MedPAC report. But most of 

them are keenly aware of that issue.

Next slide, so duals and shared savings. So the potential increases in 

utilization and cost for duals directly impact the success or failures of ACOs.

And many ACOs have a specific strategy just in targeting duals. And now 

there’s a whole new business model for population health where I see and see 

many for-profit entities running into space. And guess what their mantra is?

I can help you with the duals and we can help you realize there’s a huge 

potential in earnings and shared savings that rest in these nuggets of duals that 

are embedded in your ACO.

And so they have all kind of market material about how they identify the 

needs, and stratify it. And it really all boils down to what, providing those 

high risk consumers with services to support them in the community to reduce 

the risk of institutionalization which is what the Age and Disability Network 

has always done.
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Now for-profit entities are running in and saying ACOs bundled payment we 

can help you with your point of pain by coordinating community services to 

drive down the cost of care and reduce institutionalization for the duals.

One of the other things that was highlighted in the MedPAC report is - and 

this again is very intuitive for most of the people on the phone is that 

Medicaid home and community-based services that are targeted to reduce the 

use of institutionalization drives down the cost of Medicaid, drives down 

Medicare Part A and Part B expenditures because now we are supporting the 

person in the least restrictive environment as possible.

And by the way that’s the whole goal of the 1915 C waivers are to reduce 

institutionalization for Medicaid and the dual eligibles that are high risk for 

institutionalization.

Next slide, so shared savings and quality, each year ACOs must submit their 

quality data to CMS. And so they literally every year between January and 

March they are given a list of consumers that they have to report their 

measures on.

And there’s a portal that opens up and it opens up around January and then 

closes sometime in March. And they have to get all of their data in.

What’s important with these 33 quality measures a lot of them are all or 

nothing. So if you don’t have the data then it’s assumed that you failed on that 

measure.

And if you are asked to report on multiple consumers and you don’t have data 

on those consumers then you will fail.
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And if you don’t meet a minimum threshold in reporting data on consumers 

then the ACO will first get a request for a corrective action plan.

And then if they repeatedly fail then they will be terminated from participation 

in the ACO program.

Next slide, so there are four quality measure domains. One is the patient 

caregiver experience. And the patient caregiver experience, a lot of that is 

done by cap surveys. The other one is care coordination and patient safety, 

preventive health, and then at risk population health management.

And that - this was the ACOs have to report specific measures on diabetes, 

hypertension, ischemic, cardiovascular disease and coronary artery disease.

Next slide, so the ACO quality measures for the patient caregiver experience 

as you see these are very subjective measures and they’re are done by an 

independent survey where a representative of a sample of beneficiaries in the 

ACO are randomly contacted by a third party entity.

CMS has a list of approved entities to do these surveys. And then the ACOs

consumers and beneficiaries are asked these questions.

And then there’s a score and then that is provided at a later time to the ACO.

So it’s very - it’s not for the patient caregiver experience domain. There’s very 

little that the ACO can actively do at the time of reporting to impact these 

measures.

Next slide, the care coordination patient safety domain is a little different. 

This is where you see this, the first one on the list and show this for anyone 
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that’s participated in CCTP and other care transition activity you see that the 

all cause readmissions is the number one thing on the list.

And so ACOs are rated and scored based on all cause readmissions for the 

population of Medicare beneficiaries that they’re serving.

This again includes non-dual eligibles, dual eligibles, end-stage renal disease 

so this is all cause readmissions.

Next are ambulatory sensitive admissions. And you may not have heard that 

term before, ambulatory sensitive admissions.

And what - essentially what an ambulatory sensitive admission is, it is when a 

consumer is admitted to the hospital and the cause of the factor that made that 

consumer have that admission was something that could have been easily 

addressed in an outpatient setting or an ambulatory environment.

So an ambulatory sensitive admission for something like asthma or COPD I 

lost my inhaler I couldn’t get a refill I forgot to call in I ran out - I’m in the 

donut hole so I couldn’t afford my inhaler so I didn’t take it and now I’m short 

of breath and have to get admitted.

All of those are ambulatory sensitive. And so that person, that admission 

could have been adverted if there was some targeted interventions done in an 

outpatient basis so that person should not have been admitted.

So ACOs are rated and scored based on the percentage of their beneficiaries 

that have ambulatory sensitive admissions. Next are ambulatory sensitive 

admissions for congestive heart failure.
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The percent of PCPs that meet minimal meaningful use standards, medication

reconciliation after discharge and lastly screening for fall risk.

And so that screening for fall risk is again the percentage of ACO participants 

that are in an ACO that are screened for their risk of falls and once they - and 

if they screen positive the ACO is to refer them to a fall risk reduction 

program and so they’re rated and scored based on the ability to achieve high 

ratings in these specific measures.

Next slide, preventive health, this includes things like influenza, 

pneumococcal vaccination. A big one that many ACOs struggle with is 

depression screening.

So the number of ACO beneficiaries non-duals, duals, end-stage renal disease,

what is the percentage that were screened for depression? And if they’re

screened positive obviously did they get some treatment?

So remember the attribution process where it is a total count that wherever 

who had the preponderance of primary care claims for that beneficiary the 

assignment is made.

And so I’ve had the opportunity to see ACOs, to listen to providers when at 

the moment in time when they get their attribution list. And many of them are 

absolutely shocked because they see people on the list one that they never 

heard of.

Or they see people on the list that they may have seen one time in the past 

three years. Well guess what, they didn’t get any primary care from anybody 

else so tag you’re it. It’s now your beneficiary.
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A good one that I’ve seen multiple times or physicians say, “Well that person 

has a balance in my practice and so I banned them from coming to my 

practice so they can’t come until they pay that balance that they owe me.”

Guess what that’s - its population health buddy. So you have to manage that 

person’s health. And so you can’t talk about they didn’t pay me and so I’m not 

going to serve their needs. Don’t service their needs you’re going to be subject 

to meeting poor quality measures for that beneficiary.

Another one that I often see is well these people live in assisted living and 

every time I try to schedule them to come in its always something happens.

They don’t get transportation, they don’t come. By the time they get to my 

practice they miss their appointment time so we have to cancel. I hardly ever 

see them so how can I be held accountable?

Again its population health. You are responsible for the whole population 

including snowbirds and so forth.

Another good one that I often hear is well I’ve only given that person, they 

only come to my practice for the flu shot. And then they get all of their other 

care from a specialist. Well the attribution it spurs to the primary care 

provider.

And then if they have no primary care claims then the specialist. So you’d be 

surprised how many primary care providers see in there attribution cancer 

patients, orthopedic patients, chronic back pain patients that they’ve never see 

unless it’s a sick visit.

And if it’s a sick visit are they’re doing a hemoglobin A1C? Are they doing 

all of the preventive health measures? They’re likely not. And so then again 
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they’re at risk for meeting all of these quality measures because it’s for the 

preponderance of the entire population that’s attributed to them.

And again if they can’t - if they don’t have the data so I don’t know if that 

person got a flu shot or not I fail that measure. It doesn’t count that I couldn’t 

reach them or they got the influenza shot at a health fair or the senior center 

was given free influenza shots so they didn’t want to come to my practice and 

get their influenza shot and I can’t prove they got it at the senior center I still 

fail.

So if I don’t have proof that occurred and I’m the provider then I fail that 

measure for that consumer.

Next slide, so next are the at risk population. So I highlighted diabetes. Many 

of you are providing things like patient activation diabetes self-management 

training and so forth.

Well there’s a specific carve out looking at just diabetes so the diabetes 

composite looking at the number of beneficiaries that have A1C that is control 

which is considered at less than eight and you see at the bottom the number of 

consumers that are - have poor control is greater than nine.

And once again if there is no A1C on file for that year then I feel that 

measure. I did not - I could not report.

It doesn’t matter that the person couldn’t get in, didn’t have transportation,

came after hours, didn’t pay the lab bill -- none of that matters for the ACO.
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They’re in the ACO. You have to report. If you have to report on that

consumer you don’t have the data then you fail that measure for that 

consumer.

Next slide, at risk population again, hypertension ischemic vascular disease

and coronary artery disease. So many of these measures are looking at 

medication adherence and so are they on the appropriate medication? Are they 

actually taking that medication?

And again if they’re in the donut hole and so they weren’t compliant with 

their medication or didn’t have the means or they made a decision for 

whatever reason not to take it I still fail the measure because it’s about the 

overall population health for the consumers that are attributed to the ACO.

Next slide, so in the overall scoring each of these domains has a particular 

weight and there’s four domains and each domain has a 25% weight.

So if I have excellent caregiver experience and I fail on preventive health, I 

fail on readmissions and I fail to manage the diabetes then I’m going to fail 

the program.

And so the cumulative weight of each of the 25 person supply is attributed to 

each domain. The cumulative total is 100%.

Next slide, so there is a sliding scale measure scoring approach. So points are 

earned based on the comparison of individual ACO stores. And the total 

points are earned for each domain is summed up and then the ACO is given a 

final overall quality score.
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Next slide, so the analysis of that score for most measures the higher the level 

of performance then the higher the number of points.

For some the - a lower score is better and those that you would guess.

Obviously that we don’t want more readmission, we want lower readmission 

so we want low as score as possible there.

We don’t want ambulatory sensitive admissions. We want the least amount of 

ambulatory sense of admission so we want a lower score there.

We want diabetes A1Cs. We want the least number of people to be listed as in 

poor control.

Next slide, so it’s a sliding scale measures scoring approach. And so now all 

of the ACOs are rated based on quality and then based if there in the 90th to 

30th percentile there’s points attributed.

If you fall below the 30 percentile then there are no points. And then that 

gives you an overall total score. If you are an ACO and you want to be in the 

80th percentile or greater for as many measures as possible.

Now the way the shared savings is earned remember the slide where I talked 

about in ACO can earn anywhere between 50% to 75% of the savings that 

they create and it’s up to because they have to improve quality and reduce 

cost.

So an example if I’m a Medicare shared (unintelligible) program ACO so I’m 

- this is a - I’m a group of provider in Tim’s ACO. And we have 10,000 

Medicare beneficiaries and we work really hard to bring down total cost of 

care.
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And we saved the Medicare Shared Savings program $20 million over the 

course of the year through intensive care coordination. We partnered with the 

AAA. We flooded all of our high risk dual eligibles with home and 

community-based services.

We averted all of those nursing home admissions and we really brought down 

the cost of care for that population.

However I wasn’t able to capture all of the data on my beneficiary so I failed 

in quite a few of the measures.

And now I come in at the 60th percentile for all of my quality measures. But I 

saved the program $20 million. There’s a complicated formula on the backend 

but in a nutshell just to give you a broad understanding of the way this is 

applied.

Because I only scored 60th percentile on my quality measures that - as an 

ACO I earned $20 million. I’m eligible for up to 50% of that which would be 

$10 million. But because I only scored in the 60th percentile I’m only eligible 

for 60% of the $10 million.

So I can get 60% of 50% that I actually earned because I did not score well 

enough on my quality measures.

Next slide, so I’d pull the 2014, 2014 mean ACO performance rating for all 

ACOs. So this is the average mean ACO scores. This is live data for all of the 

ACOs across the country for 2014. And this is how they scored.
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So for fall screening risks 46%, 46.71% actually screened of the population 

was screened for fall risk and placed into a program.

Now remember I wanted to be in what, 80th percentile and I’m saying that on 

average most ACOs scored around 46% so tremendous room for improvement 

is clearly there.

Influenza, 58%, pneumococcal 56%, depression screening 40%, so and when I 

talk to ACOs that is exactly what they said especially since they have to 

screen as many consumers as possible, screening them for depression getting 

them into a program. And then addressing that depression score is a huge 

problem.

So I’m a community-based organization and I have a PEARLS program. I 

have or - or I have another - I forget the other evidence-based program for 

screening for depression. And I marry that with an ACO and I know that on 

average ACO is only scoring about 40% and they need to get to 80% or better 

so they can make sure they get the maximum amount of savings they earn.

It would be a shame for them to do all that work, earn savings and not get the 

maximum amount of money that’s eligible to them only because they could 

not screen enough of their high risk beneficiaries for depression.

Health promotion and education 58%, all condition readmissions lower is 

better 15% on average. And medication reconciliation that was actually pretty 

high at 82%.

Next slide, and so I brought back up these percentile numbers just to highlight 

potential points of pain. So if you see 40th percentile or 40% is way down on 
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the list. And they only get a 1.25 points out of two quality points if they wind 

up in the 40th percentile.

So an ACO really needs to get 80% or more. And so if I identify that the mean 

score is at a certain level and I have a program that can help that ACO 

improve that level that’s where a point of pain meets my strength. I have a 

program for that and we can match that to help them improve that score.

Next slide, some additional mean ACO performance ratings and again this is 

live data. So the diabetes composite score rating around 26% so tremendous 

room for improvement.

A1C poor control 19% so lower is better. I want that number to be as low as 

possible.

Proportion of adults who had blood pressure screened in the past two years

60%. I was shocked at that. This is the Medicare beneficiary population.

I mean what’s the first thing that happens when you go to the doctor is

somebody checks the blood pressure. So if only 60% are actually even having

their blood pressure checked that’s telling me they’re not even getting in for 

primary care.

They feel it’s not even touching 40% of the population if they’re only able to 

just document that they have a blood pressure rating of 60%. So where is that 

- where is the rest of that population that’s attributed to them?

Well what the ACOs are saying is it’s those duals. It’s those people and 

skilled nursing facility. It’s those people in assisted living. It’s those people 
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that are “noncompliant.” They don’t come in and I need help with those.

Clearly they do.

Next slide, again looking again at the sliding scale approach and then looking 

at just on blood pressure check in the past few years we’re at 60% is the mean 

score. There is tremendous room for improvement.

And so ACOs that are coming in at the mean average are still, you know, 

they’re only getting 1.55. That’s something that on the surface should be an 

easy measure to knock out of the park.

Next slide, so the alternative payment model, so to highlight the points of pain 

I have lots of - I have had tremendous opportunities, it’s been great fun talking 

and meeting with groups working with ACOs and hospitals.

And oftentimes we from the ACO director or from the readmission 

coordinator that oh, we have it all wrapped up.

We don’t need any help. We know we have this thing locked up. We had the 

best technology. We’re risk stratifying. We’re analyzing. MedPAC says 

something totally different.

They’re saying that there is concern from hospitals, especially hospitals and 

ACOs that large numbers of hospitals that serve the poor tend to have higher 

readmission rates.

And if they’re having higher readmission rates what’s the quality measure for 

the ACO? Quality measure for the ACOs is all college readmissions,

ambulatory sensitive admissions and hospitals based on a MedPAC report.

June 2013 on Pages 106 and 107 that - where its they specifically have 
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documented that hospitals with higher share of poor patients that’s indicated 

by Medicare beneficiaries on SSI tend to have high readmission rates, have 

higher penalties as it relates to readmissions and higher per capita cost.

So that means from a shared savings perspective a point of pain for those 

hospitals would be consumers that are poor and who in the Medicare program 

categorically would meet that requirement.

Your SSI population would also be your dual eligibles. Those are consumers 

that get low income subsidies. Those consumers that are 1915 C waiver 

eligible because they have - they are Medicaid eligible. That is the same group 

that the MedPAC Report has proven have the most readmissions and hospitals 

have the least ability to address readmissions and, i.e., cost for that population.

Next slide, so because of that MedPAC report there is actually were two bills 

that were introduced. So Senate Bill 2501 the sponsor was Senator Joe 

Manchin, a Democrat from West Virginia. That - the status of that bill has 

been referred to committee on finance. And it - the cuts of this bill is that it 

provides a mandate for CMS to develop a special risk adjustment to account 

for patient socio-economic status.

And all of the major hospital groups, physician groups had great fanfare in 

support and rah-rah around this bill. And so they all submitted letters of 

support.

You should Google those. Some of the sites that have requested that 

information for me I will provide, those that information to you where you can 

see where organizations like the American Hospital Association, the 

American Association of academic Medical Centers, the Association of 
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essential hospital which are the safety net hospitals all have come out in 

categorical full-fledged support.

And they all have said that consumers that have low social economic status 

have - have higher costs, have more readmissions. And they want a special 

provision to adjust for social economic status because it’s too hard to address 

the needs of that population base.

So again if I’m a community-based organization and I have a long history of 

working with high risk vulnerable populations in my community that may be 

of lower social economic status, i.e., eligible, dual eligibles, those that are 

waiver eligible.

And I have older American Act Services, I have this engine to deliver services 

to that population. And I have every major hospital association group in full 

support saying that we need help as it relates to those population of 

beneficiaries that have low social economic status there is an opportunity.

The opportunity is created because there’s a point of pain. They’re saying they 

cannot address that point of pain. If I have a solution for that point of pain 

now let’s talk about a contract model.

Next slide, so there’s a house. There’s a separate House bill, HR 1343. And 

it’s establishing the beneficiary equity in the Hospital Readmission Program 

Act of 2015.

This bill is - now it would be a committee on Ways and Means. And this - the 

essence of this bill it requires the HHS Secretary to make a risk adjustment 

based on the proportion of inpatients who are full benefit dual eligible.
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So again we are stating the hospitals again they are all in full support of this 

bill as well were they said that they need a risk adjustment based on the 

proportion of dual eligibles that we see.

And they wanted a second adjustment to take into account the social 

economical status of the entire population in their catchment area because 

they said even if I have a non-dual the fact that I’m serving consumers that are 

originating from an area that has low social economical status well guess 

what?

Those same consumers are faced with food deserts, lack of access or 

transportation, lack of access to primary care, lack of access to pharmacy and 

other things.

And the hospitals feel as though they need a special exemption to adjust to 

mitigate the risk that they will face a penalties for readmission for that

population.

Well I’m sure nine times out of ten any community that I’m in there’s

probably a network of community-based organizations that are already 

working with that same population that these hospitals said that they have the 

most points of pain with. And they’re doing as part of their mission driven 

focus to serve the needs of those consumers.

They don’t realize always that that’s a point of pain for a hospital that’s now 

in a risk-based model. And so there’s a potential for contract. And even if we 

could maximize if I was a community-based organization and I had a contract 

for home and community-based services where I could be reimbursed whether 

that to be managed long term service support or directly for Medicaid.
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And if I’m partnering with a hospital that says that this is their largest point of 

pain it becomes a tremendous upside opportunity to me to be the exclusive 

provider for home and community-based services targeting those high risk 

beneficiaries that are at risk for institutionalization that are in that institution 

involved in the bundle payment, involved in the ACO.

And not only can I help them but I want to participate in the game sharing, the 

shared savings on the back end by my work in the community to drive down 

the cost of care and let’s stratify out the group that you already said is your 

biggest point of pain. And that’s dual eligibles and consumers in lower social 

economic status.

And by the way 20% of the Medicare population are dual eligibles. So if you 

look at - if you were in an area - I was looking at an area one of the biz 

acumen group where they have about 150,000 Medicare beneficiaries in their 

market.

So now we’re talking about 20% of 150,000 consumers. That’s a sizable 

market share.

And now if I’m partnering with this same facility I’m addressing their point of 

pain then I would work with them to go to the Medicare Advantage plans in 

the same market and say collectively I want you to be - I’m helping you on 

one side and I want you to help me advocate and negotiate with his Medicare 

Advantage plan for a carved out rate for my home and community-based 

services or my care transition program for the Medicare Advantage population 

as well.

And now I’m - I have a multitude of revenue streams throughout the 

marketplace for my services. I have multiple payers buying my services and I 
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do not have an increase in instrumental cost to serve those additional 

contracts.

Because if I have one care coordinator at one hospital, they could serve a 

Medicare dual eligible in Bed A. They can serve a Medicare Advantaged

person in Bed B. They can serve a dual SNP plan in Bed C.

And I would not have to hire additional care management to serve the needs 

of those three contracts but I’d be paid by three resources. And I’d get my foot 

in the door by negotiation to flood the home community based services for 

that group of high risk beneficiaries, at risk for institutionalization that the 

facility has already said is their highest point of pain.

And as I said for all of these bills there’s letters of support, there’s high praise 

and acclimation from all of the major groups such as the American Hospital 

Association, the Association of Academic Medical Centers, the Association of 

Essential Hospitals, just your safety net hospitals all are in full support of 

getting a special provision to adjust penalties based on the percentage of dual 

eligibles and the percentage of low income consumers that they serve.

Next slide, so the Medicare Advantage plans -- and I know this isn’t’ the 

Medicare Advantage Quality Report but this is the third fourth in the series --

I also thought this is also interesting.

So last time I talked about CMS did a study of social economic factor and its 

impact on Star ratings. So that was released in September 8 of 2015. And 

again I will make this - the slides that CMS presented the results of this data 

available to all the groups.
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But beneficiaries with low social economic status was assessed by CMS based 

on those Medicare eligible beneficiaries that elected a Medicare Advantage 

plan or dual SNP plan that also received a low income subsidy or LIS and/or 

were dual eligible.

And the study found that 12 out of 16 Star measures had a statistically 

significant negative association with low income subsidy or dual eligible 

status.

That means the 12 out of the 16 measures there was a direct very strong 

correlation between being in low income subsidy or dual eligible, i.e., being in 

a low social economic status with a poor Star rating as it relates to all cause 

admissions, medication adherence and diabetes and heart disease measures.

And one thing that was important about all cause remissions CMS’s own 

report said that for all cause admissions if any of you are familiar with 

something called P values which is a statistical - it’s a measure of statistical 

significance.

And so there’s a P value for not to get too technical but 95% confidence 

interval essentially is strong evidence. And usually a standard P value is a .05.

For all cause readmissions the strength in the correlation between low income 

subsidy and dual eligible status was almost was 10 times statistical 

significance showing that there’s a tremendous correlation between all cause 

readmissions and dual eligible status and so that’s within CMS’s own report.

So it very much correlates see everyone’s speaking in concert in tune. You 

have MedPAC saying there’s - that there’s a correlation. You have Congress,

you have the Senate, you have the House all saying that there is a correlation.
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And now CMS is saying this is a statistically significant very significant based 

on their own data showing that there is a correlation.

So now if I am, again if I am a community-based organization and I have a 

intervention that can serve that population by the way is at least 20% of the 

population in any given market. I’ve now carved out a niche.

And I can go to a facility and I can show them that their own trade 

associations are saying that they can’t handle that group. So why can’t we 

work out a happy medium where I could be the preferred provider of home 

and community-based services to drive down institutionalization to improve 

the outcomes for this group?

Next slide, so see you the opportunity. I really believe that if you could 

stratify the population. So if you go into a facility especially a facility that’s 

invested heavily in their care management resources in their data systems -

and believe me they are spending goo goo gobs of money on data systems and 

population health analysts systems.

So if you go in there and say well I mean I really want a contract and I want a 

contract to provide X service they’re going to say I’ve already spent a ton of 

money. I know I can do this. I don’t need a lot of help.

But when you begin to sing a tune where I know you have a great program, I 

know you have a great care management model, I know you have case 

managers, I know you have strong systems but if we can stratify a subset of 

the population where your providers, physicians, hospitals, hospitalists are 

having challenges with and I have a target based intervention for that group 

then that becomes to set the stage for an opportunity to move from just a mere 

discussion about an opportunity to somewhat targeted focus time on a subset 
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of the population that pretty much everyone has said they can’t have handle if 

you were to go about it that way.

Next slide, so it’s important to in all of these contract models understand what 

the consumer needs versus what the customer needs. And the consumer 

obviously is the person you’re serving.

Next slide, so the customer, the customer needs is data, data and more data. 

And the reason data is important remember I gave the example of if an ACO 

can’t find the person, can’t get them in so and then they have to report on a 

measure if they can’t report on the measure they fail.

So I’ll give you an example of I have a strong fall prevention program and I 

partner with an ACO. And that ACO wants me to provide services to those 

beneficiaries.

I screen them for fall risk. I do a time them up and go. I do a Tinetti. I 

document their attendance. I do a knock out the park homerun in serving that

population.

I have 100% attendance at every program. Consumers are finishing my fall 

prevention and staying for my enhanced fitness program and they want more 

strength and then balance. They can’t get enough of my work.

But I can’t document it. And I can’t document it in a way that the ACO can 

take credit for it, i.e., make its way into their EHR. Then it’s just like I didn’t 

do anything. I wasn’t a benefit to the ACO.

Because if they can’t report it, if they can’t pull it out of their DHR and prove 

that that beneficiary was screened for fall risk, they had a time them up and 
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go, they had a Tinetti, and then they had an intervention then I failed the 

measure. So data, data, data’s king.

And if I was a community-based organization and I’m - if I decide or I’m 

working with this great hospital and I have this program again fall prevention 

and I fax over the Tinetti scores, I fax over the tie them up and go, I fax over 

the attendance record and then say they take this extra step of they scan in that 

information into their EHR, remember when I said the reporting period for the 

ACO? The ACO is given a list of all of all the beneficiaries they have to 

report on and which specific measures they have to report on because they 

don’t know before that time. They’re not presenting. They’re not submitting 

on 100%.

So they’re given a random sampling of beneficiaries and specific measures 

they have to report on those beneficiaries. They’re given that in January. They 

have till March to report that.

Again I give the example of BJC Healthcare in St. Louis. They have 50,000 

lives. So now they’re given - they have to report on say 30,000 of those 

beneficiaries for fall risk.

They are not going to have the time to go through and say oh yes Tim’s CBO 

sent us a bunch of scanned records or scanned handwritten documents. And 

now somebody needs to sit and manually go one by one through all those 

scanned images and read through my broken handwriting to see if that person 

was actually screened for fall risk. They’re not going to do it. They’re just 

going to move on.

And unfortunately what I’m seeing more and more there’s four competencies 

that are coming in and saying I have a program and I’m going to document 
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and I’m going to send the data back to you. And it’ll come back electronically 

so it can be incorporated into your EHR. And then you’ll have a check in the 

box for all of your measures.

So data, data more data, data’s king for ACOs data’s king for Medicare 

Advantage so we’ve got to get them over. We can provide data.

And so that’s how we can contribute to improve on quality and reducing 

financial risk.

Next slide, so the next steps know your market, know your competition. 

Competition is heating up.

To fall there’s a lot of big changes that are really heating things up. One, I tell 

you about the alternative payment models, macro legislation for Medicare 

Advantage plans.

The last Webinar I talked about how beginning in 2016 which is a few months 

from now and we’re then we’re going to be in 2016.

So Medicare Advantage plans that continue to score a three or worse after 

2016 will no longer be in the Medicare Advantage program. And we’ve 

already proven it’s based on CMS’s data that 12 out of the 16 Star measures 

ACOs are directly impacted based on the percentage of dual eligibles or 

consumers with low income subsidy that are in their plan.

So those plans do they have a point of pain, absolutely. Are they at risk?

Beginning 2016 if they don’t fix the vast majority of their population to get 

them to the 80th percentile and they continue to score at a three star or worse 

they will no longer be a Medicare Advantage plan. So it is do or die time.
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And so they are looking for solutions. If I have a solution that’s targeted to 

their point of pain there’s obviously opportunity for contract.

Next slide, so that’s the end and I’d love to field any questions there may be.

Lauren Solkowski: Great thank you Tim. So operator if you could now provide instructions 

for asking a question through the phone that would be great.

Coordinator: Thank you. At this time if you’d like to ask a question please press Star then 1 

on your phone and record your first and last name clearly when prompted.

Again if you would like to ask a question at this time over the phone please 

press Star then 1 and record your first and last name clearly when prompted.

One moment for your first question.

Lauren Solkowski: Thank you. Let’s see so we did have a question come in on the chat. It 

says if there - if okay sorry.

Is there a minimum number of customers to qualify as an ACO? If so what -

are the rural areas going to become ACO approved?

Tim McNeill: That’s an excellent question. And I thought I had that slide in there but you 

just reminded me that I must have - when I organize my slides I must have 

muted that one.

So the Medicare Shared Savings programs ACO must have a minimum of 

5000 beneficiaries. A Pioneer ACO although there’s no more Pioneers or no 

new Pioneers but they have to have a minimum of 15,000.
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So they have to have that minimum number to start and then they have to 

maintain that minimum throughout the duration of their participation in the 

ACO.

So if - and so if people die, they leave the ACO, if they start getting more of 

their primary care from a non-ACO provider, they leave the ACO, if they 

elect that’s open enrollment period right?

So now if they elect Medicare Advantage once that consumer elects to go into 

a Medicare Advantage plan they come out of the ACO.

So an ACO is always at risk of going - if they’re right at 5000 they’re always 

at risk of going below 5000. If they go below 5000 they get a nasty gram from 

CMS and they better do something about it.

And they better do something quick. If they don’t and if they fail to do 

something pretty quickly then they will be asked to leave the program because 

you’ve got to have met the minimum threshold.

So how does an ACO add lives, add beneficiaries? They have to recruit more 

doctors.

So if I - and so in the rural areas a phenomenon that we’re seeing is - let me 

take it back. So many ACOs have begun to see just like with the Medicare 

Advantage plans there’s strength in numbers.

The more the larger the population the less a bad score or a bad or a bad mix 

of consumers will impact your quality ratings.
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The larger of the population the more it washes out. It’s a law of averages.

The bads outweigh, excuse me, the goods outweigh the bad the larger the 

population is.

But if I have so if I only have 5000 lives if I’m right at the minimum and I 

have say one bad physician that has 1000 lives that doesn’t participate or has 

very poor quality I’m failing. I’m already failing because one out of five are 

already scoring badly. So they want to get as large as possible.

So in the rural areas and in well many areas you have consolidation of ACOs

just like you have consolidation of Medicare Advantage plans where they’re 

consolidating to get larger and larger.

And in the rural areas you have ACOs that are operating in multiple states.

And so one of the largest ones serving rural areas is an ACO called rural

ACO.

And they serve multiple states and they specifically target physicians in rural 

areas and they ban them all together to get the numbers they need.

So now the rural ACO has, you know, 10,000, 20,000 lives and those 20,000 

lives are made up of hundreds of small rural providers. And some of those 

rural physicians may only bring in 100 - excuse me, 100 beneficiaries.

I was at a presentation in DC and there was a group of minority physicians in 

DC and they all had very small numbers of Medicare. They served a lot of 

Medicaid. And each of them only had 100 Medicare lives in their panel.
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And so in order to get to the 5000 number they had to get a whole lot of 

doctors that had 100 to get to 5000. That particular group never, they were 

never able to get to 5000 so they didn’t even get in but that’s an example.

Next slide.

Lauren Solkowski: Thank you Tim.

Tim McNeill: Oh I’m sorry not next slide, other questions? I’m sorry.

Lauren Solkowski: It’s okay. Operator have we had any questions come in on the phone?

Coordinator: There are no questions over the phone lines.

Lauren Solkowski: Okay. I’m not showing other questions on the chat. We’ll give it another 

minute or so just in case anything else comes in.

In the meantime I just wanted to remind everyone that since we have our next 

in person meeting with our learning collaborative members coming up the 

first week in November. We will not be hosting a topical Webinar in 

November.

So we’re looking to schedule the next Webinar for December 2015. So there 

will be more to come on that. Okay let me just check back.

Okay there is a question, one second. Okay the next question says how and 

when do beneficiaries who are recently enrolled in Medicare become involved 

with an ACO?
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Tim McNeill: So generally a beneficiary has to have a - has to have data in the ACO excuse 

me, been in the Medicare program for a year to count.

And so during that - so if they enroll they just become Medicare eligible this 

year say they just turned 65 or they were eligible based on a disability 

beginning this year over the course of the next 12 months if that consumer 

gets the bulk of their primary care from a physician or practice as part of the 

ACO then the next cycle that consumer will be attributed to that ACO.

And actually every quarter the ACO - the ACOs get an update of their 

attributions and so they get updated the number of beneficiaries that have been 

added or deleted during the quarter.

And so and consumers can be deleted based on joining Medicare Advantage 

and they can be added based on joining the Medicare program.

Lauren Solkowski: Great. Okay there is another question that has come in. Let’s see are their 

existing data systems that work well with ACOs that would work for Older 

American Act programs?

Tim McNeill: So the office of the National Coordinator and it’s an odd name but - or I 

believe it’s an odd name. But the office of the National Coordinator is part a 

Department at HHS and they govern health IT policies. And they have 

established something called meaningful use standards.

And all hospital systems, all providers systems that receive a EHR, Electronic 

Health Record incentive payment has to be made those meaningful use 

standards.
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And any system that meets meaningful use standards automatically by 

definition can communicate and share data with any hospital and any 

physician that’s also held to the same meaningful use standards.

And so if you are operating or choose a platform that meets meaningful use 

standards you automatically can communicate with everybody in the market 

that’s also meeting meaningful use standards.

And right about now any major player hospital or physician is either meeting 

meaningful use or aggressively working towards meaningful use.

And the rules for meaningful use require that any meaningful use certified 

product has to be able to exchange information and receive information with 

another meaningful use certified product.

So as long as you have a meaningful use certified product you are going to 

meet the requirement.

And there’s a long list of meaningful use certified products out there. The 

Office of National Coordinator publishes a list of those products that meet 

meaningful use standards. And so getting a system that is on that list is 

important.

Another thing that I just - that I also think is important is that with - many of 

you have heard about the new chronic care management billing codes for 

providers of Medicare’s reimbursing for non-face-to-face care coordination 

for beneficiaries with two or more chronic conditions.

And then there’s all - there’s been the code is chronic care management or 

CCM is collectively referred to as CCM. And it pays a per person per month 
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rate for care coordination services for a beneficiary with two or more chronic 

conditions.

And then there’s the TCM or Transitional Care Management codes which 

pays for care transition services for Medicare beneficiaries.

So what’s important is that CMS in the final rule for CCM services or chronic 

care management services for one of the first times in memory they came out.

They CMS specifically outlined that in order to bill for those services a 

provider and/or the network of people doing care coordination supporting 

those beneficiaries have to do it in a meaningful use certified product or else 

you cannot bill.

And so that I believe is almost like a line in the sand that we all have to - and 

whether you’re doing care management, care coordination, transitional care 

management, direct services we are all having to move to a platform the meets 

meaningful use standards in order to survive long term.

And what I am seeing in the for profit space is those groups that are able to 

negotiate contracts for care transitions and other services they’re all using the 

meaningful use certified product. They’re exporting that data back to the 

ACOs and hospitals. It’ being absorbed automatically absorbed right into their 

EHR.

So now when the next time that provider opens up their system they’re seeing 

what that for-profit entity did. It’s already incorporated part and parcel with 

their EHR because they’re both on a meaningful use certified platform.

Lauren Solkowski: Okay operator I will check back with you to see if you’ve had questions 

come in?
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Coordinator: There are no questions on the phone lines.

Lauren Solkowski: Okay thanks. We have another question in the Webinar. It says what type 

medication reconciliation model do you think is most effective in the EH CBS 

setting as delivered by a CBO? How “clinical” does it need to be?

Tim McNeill: So that the medication reconciliation requirement is based on the rules for 

medication reconciliation or the guidelines that are set forth by NCQA.

And so they have very explicit instructions on medication reconciliation in 

order to meet the requirement to qualify.

And it requires a final review of the medication of all of that consumers 

prescribed medications, over the counters, herbals, and anything else that

consumer’s taking in the way of medication or not taking. It has to be 

collected, has to be reviewed and then there has to be a direct encounter with 

that consumer and a pharmacist in order to meet the requirements for NCQA.

And so if that pharmacist, the pharmacist can absolutely work with a 

community based program and a home community-based environment where 

community program is capturing that information, documenting it, sharing it 

with the pharmacist.

But the pharmacist has to have a direct encounter with that consumer and it 

can be via Telehealth. So that pharmacist can have a secure Skype encounter 

with the consumer, a telephone encounter with the consumer.
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And during that time that pharmacist must review all of their prescribed 

medication, their over the counters and their herbals and make 

recommendations.

If I was a community-based program and I’m working with a pharmacist and 

they’re checking for only medication that may cause a problem or they’re only 

looking at their prescribed medications, they’re not looking at over-thecounter and herbals it doesn’t meet the requirement.

I mean it’s very explicit what the requirement has to be it has that community 

based organization can assist with capturing the data, educating the consumer, 

linking them with the pharmacist. But then the pharmacist has to review all 

aspects of that medication regime with that consumer in order to meet the 

requirement.

And this is a new requirement for Medicare Advantage plans again this year.

It is - you see is something that all the ACOs have to adhere to. And guess 

what at the last Medicare Star conference Medicare Advantage Star 

conference I was at I saw three new startup venture capital funded entities.

And the only thing they’re doing is marketing to Medicare Advantage plans to 

help them meet the measure for medication reconciliation where they were -

these programs they were sending a community health worker in the home to 

capture the information to document it and then with an iPad link that person 

back to a pharmacist at a call center that then has a face to face interaction 

with that consumer and reviews all aspects of their medication regime and 

then documents it to meet that requirement.

So it’s created a new opportunity. And it I - if we can have a model that 

supports them in meeting that requirement that’s something we can take to 
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market and take the market quickly. But it has to meet all of those 

requirements and those requirements are set forth by NCQA.

Lauren Solkowski: Okay. Let’s see I - we are just about over. I will check back one more time 

with the operator for an audio question?

Coordinator: There are no questions at this time.

Lauren Solkowski: Okay and Tim we had another question coming but since we are at the end 

of the time I will send this to you in an email to be...

Tim McNeill: Okay.

Lauren Solkowski: So I will do that and so just wanted to thank you again for presenting on 

the series.

Our - we’ve heard from several of our learning collaborative members they 

found it extremely helpful so thank you again.

If you are - would like to access the previous Webinars from the series they 

are on the MLTSS Web site. So you can find them there.

If you have any trouble finding them please let me know and I can help direct 

you to them.

So thank you again to everyone for joining us today and enjoy the rest of your 

afternoon.

Coordinator: Thank you. This concludes today’s conference. You may all disconnect.
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END