HHS announces 89 new Accountable Care Organizations

2.4 million people with Medicare to receive better, more coordinated care

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today, that as of July 1, 89 new Accountable Care Organizations (ACOs) began serving 1.2 million people with Medicare in 40 states and Washington, D.C. ACOs are organizations formed by groups of doctors and other health care providers that have agreed to work together to coordinate care for people with Medicare.

These 89 new ACOs have entered into agreements with CMS, taking responsibility for the quality of care they provide to people with Medicare in return for the opportunity to share in savings realized through high-quality, well-coordinated care.

“Better coordinated care is good for patients and it saves money,” said Secretary Sebelius. “We applaud every one of these doctors, hospitals, health centers and others for working together to ensure millions of people with Medicare get better, more patient-centered, coordinated care.”

Participation in an ACO is purely voluntary for providers. The Medicare Shared Savings Program (MSSP), and other initiatives related to ACOs, is made possible by the 2010 Affordable Care Act. Federal savings from this initiative could be up to $940 million over four years.

“This new group of ACOs adds to a solid foundation,” said Centers for Medicare & Medicaid (CMS) Acting Administrator Marilyn Tavenner. “The Medicare ACO program opened for business in January and, already, more than 2.4 million beneficiaries are receiving care from providers participating in these important initiatives.”

The 89 ACOs announced today bring the total number of organizations participating in Medicare shared savings initiatives to 154, including the 32 ACOs participating in the testing of the Pioneer ACO Model by CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011. In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

The selected ACOs operate in a wide range of areas of the country and almost half are physician-driven organizations serving fewer than 10,000 beneficiaries, demonstrating that smaller organizations are interested in operating as ACOs.   Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving.  

To ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely, an ACO must meet quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

Beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from Aug. 1 through Sept. 6, 2012. More information, including application requirements, is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html

FACT SHEET

FOR IMMEDIATE RELEASE                                     Contact: CMS Media Relations

July 9, 2012                                                                                  (202) 690-6145

CMS names 89 new Medicare Shared Savings Accountable Care Organizations

On July 9, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the selection of 89 additional Accountable Care Organizations (ACOs) to participate in the Medicare Shared Saving Program. The selected organizations will take responsibility for coordinating care for nearly 1.2 million beneficiaries in 40 States and Washington, D.C. In total, there now are 154 organizations participating in Medicare shared savings initiatives, serving over 2.4 million Medicare patients across the country.

All ACOs that succeed in reducing the rate of growth in the cost of care while providing high quality care may share in the savings to Medicare. To ensure high quality of care, ACOs will report performance on 33 measures relating to care coordination and patient safety, use of appropriate preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

Five of the ACOs announced today applied for a version of the program that allows them to earn a higher share of any savings by also being held accountable for a share of any losses if the costs of care for the beneficiaries assigned to them increase.

Participation in an ACO is purely voluntary for providers. Because the Shared Savings Program is part of the original Medicare fee-for-service program, beneficiaries served by these ACOs will continue to have free choice about the care they receive and from whom they seek care, without regard to whether a particular provider or supplier is participating in an ACO.

Descriptions of the participating ACOs are appended to this Fact Sheet.

Background on the Shared Savings Program:

Section 3022 of the Affordable Care Act added a new section 1899 to the Social Security Act that requires the Secretary to establish the Shared Savings Program. The program is intended to encourage physicians and other providers of Medicare-covered services and supplies (e.g., hospitals and others involved in patient care), to create a new type of health care entity, an ACO, that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations, while reducing the rate of growth in health care spending. Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, partly because patients avoid unnecessary duplication of services and dangerous medical errors.

On Nov. 2, 2011, CMS published a final rule in the Federal Register establishing the Shared Savings Program. The final rule addressed issues relating to eligibility, governance, beneficiary rights, quality measures and performance scoring, and CMS monitoring of ACO operations. At the same time, the Innovation Center announced an Advance Payment ACO Model to test whether providing advance payments from anticipated savings could encourage certain rural and physician-based entities to apply to participate in the program, thereby increasing the speed at which ACOs can improve care for beneficiaries and generate Medicare savings.

In conjunction with the final rule, the Office of Inspector General of the Department of Health and Human Services, the Department of Justice, the Federal Trade Commission, and the Internal Revenue Service issued separate documents addressing a variety of legal issues as they apply to the Shared Savings Program. These included the interaction of the Shared Savings Program with the federal anti-kickback, physician self-referral, civil monetary penalty (the fraud and abuse laws) and antitrust laws, as well as the Internal Revenue Code regarding the tax implications for nonprofit entities seeking to participate in ACOs. The final rule, the notice of the Advance Payment ACO Model, and the final waivers in connection with the Shared Savings Program were published in the Nov. 2, 2011 Federal Register.

CMS also announced that, beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the Shared Savings Program beginning January 2013 is from August 1 through September 6, 2012. More information, including application requirements, is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html

More information about all ACO initiatives at CMS can be found at:

http://www.cms.gov/aco

More information about the Shared Savings Program can be found at:

            http://www.cms.hhs.gov/sharedsavingsprogram/  

Links to the statute, regulations, and guidance regarding the final rule, including the guidance issued by the federal agencies listed above can be found at:

            http://www.cms.gov/SharedSavingsProgram/30_Statutes_Regulations_Guidance.asp

SUMMARIES OF ACOS SELECTED FOR JULY 1, 2012 START DATE[1] 

Arizona Health Advantage, Inc, located in Chandler, Arizona, is comprised of networks of individual ACO practices, with 73 physicians. It will serve Medicare beneficiaries in Arizona.

John C. Lincoln Accountable Care Organization, LLC, located in Phoenix, Arizona, is comprised of partnerships between hospitals and ACO professionals, and hospitals employing ACO professionals. It will serve Medicare beneficiaries in Arizona.

Fort Smith Physicians Alliance ACO, LLC, located in Fort Smith, Arkansas is comprised of networks of individual ACO practices, with 78 physicians.   It will serve Medicare beneficiaries in Arkansas and Oklahoma.

ApolloMed Accountable Care Organization Inc., located in Glendale, California, is comprised of networks of individual ACO practices, with 130 physicians. It will serve Medicare beneficiaries in California.

Golden Life Healthcare LLC, located in Sacramento, California, is comprised of networks of individual ACO practices and partnerships between hospitals and ACO professionals, with 57 physicians. It will serve Medicare beneficiaries in California.  

John Muir Physician Network, located in Walnut Creek, California, is comprised of ACO group practices and networks of individual ACO practices, with 197 physicians. It will serve Medicare beneficiaries in California.

Meridian Holdings, Inc., located in Hawthorne, California, is comprised of ACO group practices and networks of individual ACO practices, with 60 physicians. It will serve Medicare beneficiaries in California, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, and Texas.

North Coast Medical ACO, Inc., located in Oceanside, California, is comprised of ACO group practices, hospitals employing ACO professionals, and a federally qualified health center, with 281 physicians. It will serve Medicare beneficiaries in California.

Torrance Memorial Integrated Physicians, LLC, located in Torrance, California, is comprised of partnerships between a hospital and ACO professionals, with 398 physicians. It will serve Medicare beneficiaries in California.

MPS ACO Physicians, LLC, located in Middletown, Connecticut, is comprised of networks of individual ACO practices, with 38 physicians. It will serve Medicare beneficiaries in Connecticut.  

PriMed, LLC, located in Shelton, Connecticut, is comprised of ACO group practices, with 116 physicians. It will serve Medicare beneficiaries in Connecticut.  

Accountable Care Coalition of Northwest Florida, LLC, located in Pensacola, Florida, is comprised of networks of individual ACO practices, with 60 physicians. It will serve Medicare beneficiaries in Alabama and Florida.

Accountable Care Partners, LLC, located in Jacksonville, Florida, is comprised of ACO group practices and networks of individual ACO practices, with 65 physicians. It will serve Medicare beneficiaries in Florida and Georgia.  

Allcare Options, LLC, located in Parrish, Florida, is comprised of ACO group practices and networks of individual ACO practices, with 198 physicians. It will serve Medicare beneficiaries in Florida.

Florida Medical Clinic ACO, LLC, located in Zephyrhills, Florida, is comprised of networks of individual ACO practices, with 153 physicians. It will serve Medicare beneficiaries in Florida.

FPG Healthcare, LLC, located in Orlando, Florida, is comprised of ACO group practices, with 142 physicians. It will serve Medicare beneficiaries in Florida.

HealthNet LLC, located in Boynton Beach, Florida, is comprised of networks of individual ACO practices, with 55 physicians. It will serve Medicare beneficiaries in Florida.

Integrated Care Alliance, LLC, located in Gainesville, Florida, is comprised of networks of individual ACO practices, with 115 physicians.   It will serve Medicare beneficiaries in Florida.

Medical Practitioners for Affordable Care, LLC, located in Melbourne, Florida, is comprised of networks of individual ACO practices, with 126 physicians. It will serve Medicare beneficiaries in Florida.

Palm Beach Accountable Care Organization, LLC, located in West Palm Beach, Florida, is comprised of networks of individual ACO practices, with 337 physicians. It will serve Medicare beneficiaries in Florida.  

Reliance Healthcare Management Solutions, LLC, located in Tampa, Florida, is comprised of networks of individual ACO practices, with 36 physicians. It will serve Medicare beneficiaries in Florida.    

WellStar Health Network, LLC, located in Marietta, Georgia, is comprised of partnerships between hospitals and ACO professionals, with 1,203 physicians. It will serve Medicare beneficiaries in Georgia.

Advocate Health Partners, located in Rolling Meadows, Illinois, is comprised of partnerships between hospitals and ACO professionals, with 2,237 physicians. It will serve Medicare beneficiaries in Illinois.

Chicago Health System ACO, LLC, located in Westmont, Illinois, is comprised of ACO group practices, networks of individual ACO practices, partnerships between hospitals and ACO professionals, hospitals employing ACO professionals, and federally qualified health centers, with 523 physicians. It will serve Medicare beneficiaries in Illinois.

Deaconess Care Integration, LLC, located in Evansville, Indiana, is comprised of ACO group practices, networks of individual ACO practices, partnerships between hospitals and ACO professionals and a hospital employing ACO professionals, and a rural health clinic, with 323 physicians. It will serve Medicare beneficiaries in Illinois, Indiana, and Kentucky.

Franciscan AHN ACO, LLC, located in Mishawaka, Indiana, is comprised of partnerships between hospitals and ACO professionals, with 245 physicians. It will serve Medicare beneficiaries in Indiana.

Indiana University Health ACO, Inc., located in Indianapolis, Indiana, is comprised of ACO group practices, networks of individual ACO practices, partnerships between hospitals and ACO professionals and hospitals employing ACO professionals, and a federally qualified health center, with 1,837 physicians. It will serve Medicare beneficiaries in Indiana.

Genesis Accountable Care Organization, LLC, located in Davenport, Iowa, is comprised of hospitals employing ACO professionals, with 312 physicians. It will serve Medicare beneficiaries in Illinois and Iowa.

Iowa Health Accountable Care, L.C., located in Des Moines, Iowa, is comprised of ACO group practices, networks of individual ACO practices, a combination of hospitals employing ACO professionals, a federally qualified health center and a rural health clinic, with 1,551 physicians. It will serve Medicare beneficiaries in Illinois, Iowa, and Missouri.

One Care LLC, located in Des Moines, Iowa, is comprised of partnerships between hospitals and ACO professionals, with 402 physicians. It will serve Medicare beneficiaries in Iowa.

University of Iowa Affiliated Health Providers, LC, located in Iowa City, Iowa, is comprised of partnerships between hospitals and ACO professionals, with 1,791 physicians. It will serve Medicare beneficiaries in Iowa.

Owensboro ACO, located in Owensboro, Kentucky, is comprised of networks of individual ACO practices, with 26 physicians. It will serve Medicare beneficiaries in Indiana and Kentucky.

Quality Independent Physicians, located in Louisville, Kentucky, is comprised of ACO group practices, with 74 physicians. It will serve Medicare beneficiaries in Indiana and Kentucky.  

Southern Kentucky Health Care Alliance, located in Smiths Grove, Kentucky, is comprised of networks of individual ACO practices, with 35 physicians. It will serve Medicare beneficiaries in Kentucky.

TP-ACO LLC located in Baton Rouge, Louisiana, is comprised of networks of individual ACO practices, with 50 physicians. It will serve Medicare beneficiaries in Florida, Louisiana and Tennessee.

Central Maine ACO, located in Lewiston, Maine, is comprised of ACO group practices, networks of individual ACO practices and partnerships between hospitals and ACO professionals, including a combination of hospitals employing ACO professionals. It includes 566 physicians.   It will serve Medicare beneficiaries in Maine.

Maine Community Accountable Care Organization, LLC, located in Augusta, Maine, is a federally qualified health center with 125 physicians. It will serve Medicare beneficiaries in Maine.

MaineHealth Accountable Care Organization, located in Portland, Maine, is comprised of networks of individual ACO practices, partnerships between hospitals and ACO professionals and hospitals employing ACO professionals, with 1,595 physicians. It will serve Medicare beneficiaries in Maine.

Accountable Care Coalition of Maryland, LLC, located in Hollywood, Maryland, is comprised of ACO group practices, with 109 physicians. It will serve Medicare beneficiaries in Maryland.

Greater Baltimore Health Alliance Physicians, LLC, located in Baltimore, Maryland, is comprised of partnerships between a hospital and ACO professionals and a hospital employing ACO professionals, with 399 physicians. It will serve Medicare beneficiaries in Maryland and Pennsylvania.

Maryland Accountable Care Organization of Eastern Shore LLC, located in National Harbor, Maryland, is comprised of ACO group practices, networks of individual ACO practices, with 15 physicians.   It will serve Medicare beneficiaries in Maryland.    

Maryland Accountable Care Organization of Western MD LLC, located in National Harbor, Maryland, is comprised of ACO group practices and networks of individual ACO practices, with 23 physicians.   It will serve Medicare beneficiaries in Maryland, Pennsylvania, and West Virginia.    

Circle Health Alliance, LLC, located in Lowell, Massachusetts, is comprised of partnerships between hospitals and ACO professionals, with 353 physicians. It will serve Medicare beneficiaries in Massachusetts and New Hampshire.

Harbor Medical Associates, PC, located in South Weymouth, Massachusetts, is comprised of ACO group practices, with 116 physicians. It will serve Medicare beneficiaries in Massachusetts.  

Accountable Healthcare Alliance, PC, located in East Lansing, Michigan, is comprised of networks of individual ACO practices, with 29 physicians.   It will serve Medicare beneficiaries in Michigan.

Oakwood Accountable Care Organization, LLC, located in Dearborn, Michigan, is comprised of partnerships between hospitals and ACO professionals, with 1,546 physicians.   It will serve Medicare beneficiaries in Michigan.

Southeast Michigan Accountable Care, Inc., located in Dearborn, Michigan, is comprised of ACO group practices and networks of individual ACO practices, with 333 physicians. It will serve Medicare beneficiaries in Michigan

Essential Health, located in Duluth, Minnesota, is comprised of a combination of ACO group practices, critical access hospitals, and a rural health clinic, with 1,404 physicians. It will serve Medicare beneficiaries in Minnesota, North Dakota, and Wisconsin.

Medical Mall Services of Mississippi, located in Jackson, Mississippi, is comprised of networks of individual ACO practices and a federally qualified health center, with 487 physicians. It will serve Medicare beneficiaries in Mississippi.  

BJC HealthCare ACO, LLC, located in St. Louis, Missouri, is comprised of a combination of hospitals employing ACO professionals, and rural health clinics, with 556 physicians. It will serve Medicare beneficiaries in Illinois and Missouri.

Heartland Regional Medical Center, located in St. Joseph, Missouri, is comprised of a hospital employing ACO professionals, with 199 physicians. It will serve Medicare beneficiaries in Kansas and Missouri.

Nevada Primary Care Network ACO, LLC, located in Las Vegas, Nevada, is comprised of ACO group practices and networks of individual ACO practices, with 89 physicians. It will serve Medicare beneficiaries in Nevada.

Concord Elliot ACO LLC, located in Manchester, New Hampshire, is comprised of partnerships between hospitals and ACO professionals, with 234 physicians. It will serve Medicare beneficiaries in New Hampshire.

Barnabas Health ACO-North, LLC, located in West Orange, New Jersey, is comprised of partnerships between hospitals and ACO professionals, hospitals employing ACO professionals, with 435 physicians. It will serve Medicare beneficiaries in New Jersey.

Accountable Care Coalition of Syracuse, LLC, located in Syracuse, New York, is comprised of ACO group practices, with 105 physicians.   It will serve Medicare beneficiaries in New York.

Asian American Accountable Care Organization, located in New York City, is comprised of networks of individual ACO practices, with 239 physicians. It will serve Medicare beneficiaries in New York.

Balance Accountable Care Network, located in New York City, is comprised of hospitals and networks of individual ACO practices, with 1,069 physicians. It will serve Medicare beneficiaries in New York.

Beacon Health Partners, LLP, located in Manhasset, New York, is comprised of networks of individual ACO practices, with 261 physicians. It will serve Medicare beneficiaries in New York.

Chautauqua Region Associated Medical Partners, LLC, located in Jamestown, New York, is comprised of partnerships between hospitals and ACO professionals, with 200 physicians. It will serve Medicare beneficiaries in New York and Pennsylvania.

Healthcare Provider ACO, Inc., located in Garden City, New York, is comprised of networks of individual ACO practices, with 395 physicians. It will serve Medicare beneficiaries in New York.

Mount Sinai Care, LLC, located in New York City, is comprised of networks of individual ACO practices and a hospital(s) employing ACO professionals, with 2,249 physicians. It will serve Medicare beneficiaries in New York.

ProHEALTH Accountable Care Medical Group, PLLC, located in Lake Success, New York, is comprised of ACO group practices, with 281 physicians. It will serve Medicare beneficiaries in Florida and New York.

WESTMED Medical Group, PC, located in Purchase, New York, is comprised of ACO group practices, with 250 physicians. It will serve Medicare beneficiaries in Connecticut and New York.

Cornerstone Health Care, PA, located in High Point, North Carolina, is comprised of ACO group practices, with 313 physicians. It will serve Medicare beneficiaries in North Carolina.

Triad Healthcare Network, LLC, located in Greensboro, North Carolina, is comprised of networks of individual ACO practices and a hospital employing ACO professionals, with 759 physicians. It will serve Medicare beneficiaries in North Carolina.

Mercy Health Select, LLC, located in Cincinnati, Ohio, is comprised of hospitals employing ACO professionals, with 365 physicians. It will serve Medicare beneficiaries in Indiana and Ohio.

ProMedica Physician Group, Inc., located in Toledo, Ohio, is comprised of ACO group practices and networks of individual ACO practices, with 250 physicians. It will serve Medicare beneficiaries in Michigan and Ohio.

Summa Accountable Care Organization, located in Akron, Ohio, is comprised of partnerships between hospitals and ACO professionals, with 612 physicians. It will serve Medicare beneficiaries in Ohio.

University Hospitals Coordinated Care, located in Shaker Heights, Ohio, is comprised of partnerships between hospitals and ACO professionals, with 1,770 physicians. It will serve Medicare beneficiaries in Ohio.

North Bend Medical Center, Inc., located in Coos Bay, Oregon, is comprised of ACO group practices, with 112 physicians. It will serve Medicare beneficiaries in Oregon.

Coastal Medical, Inc., located in Providence, Rhode Island, is comprised of ACO group practices, with 100 physicians. It will serve Medicare beneficiaries in Massachusetts and Rhode Island.  

Accountable Care Coalition of The Tri-Counties, LLC, located in Charleston, South Carolina, is comprised of networks of individual ACO practices, with 108 physicians. It will serve Medicare beneficiaries in South Carolina.

AnewCare LLC, located in Johnson City, Tennessee, is comprised of partnerships between hospitals and ACO professionals, with 673 physicians. It will serve Medicare beneficiaries in Tennessee and Virginia.

Cumberland Center for Healthcare Innovation, LLC, located in Nashville, Tennessee, is comprised of networks of individual ACO practices, with 33 physicians. It will serve Medicare beneficiaries in Tennessee.  

MissionPoint Health Partners, located in Nashville, Tennessee, is comprised of hospitals employing ACO professionals, with 544 physicians. It will serve Medicare beneficiaries in Tennessee.

St. Thomas Medical Group PLLC, located in Nashville, Tennessee, is comprised of ACO group practices, with 41 physicians. It will serve Medicare beneficiaries in Tennessee.  

Summit Health Solutions, located in Knoxville, Tennessee, is comprised of hospitals and ACO group practices, with 474 physicians.   It will serve Medicare beneficiaries in Tennesse.

BHS Accountable Care, LLC, located in San Antonio, Texas, is comprised of ACO group practices, networks of individual ACO practices, partnerships between a hospital and ACO professionals and a hospital employing ACO professionals, with 348 physicians.   It will serve Medicare beneficiaries in Texas.

Memorial Hermann Accountable Care Organization, located in Houston, Texas, is comprised of networks of individual ACO practices and partnerships between hospitals and ACO professionals, with 332 physicians. It will serve Medicare beneficiaries in Texas.

Methodist Patient Centered ACO, located in Dallas, Texas, is comprised of ACO group practices, networks of individual ACO practices and partnerships between hospitals and ACO professionals, with 269 physicians. It will serve Medicare beneficiaries in Texas.

Essential Care Partners, LLC, located in Austin, Texas, is a federally qualified health center with 275 physicians. It will serve Medicare beneficiaries in Texas.

Physicians ACO, LLC, located in Houston, Texas, is comprised of networks of individual ACO practices, with 75 physicians. It will serve Medicare beneficiaries in Texas.  

Texoma ACO, LLC, located in Wichita Falls, Texas is comprised of ACO group practices and networks of individual ACO practices, with 52 physicians.   It will serve Medicare beneficiaries in Texas.  

Central Utah Clinic, P.C., located in Provo, Utah, is comprised of ACO group practices, with 173 physicians. It will serve Medicare beneficiaries in Utah.

Accountable Care Coalition of Green Mountains, LLC, located in South Burlington, Vermont, is comprised of ACO group practices and networks of individual ACO practices, with 42 physicians. It will serve Medicare beneficiaries in Vermont.

Polyclinic Management Services Company, located in Seattle, Washington, is comprised of ACO group practices, with 296 physicians. It will serve Medicare beneficiaries in Washington.

Aurora Accountable Care Organization LLC, located in Milwaukee, Wisconsin, is comprised of ACO group practices, with 275 physicians. It will serve Medicare beneficiaries in Wisconsin.

Dean Clinic and St. Mary's Hospital Accountable Care Organization, LLC, located in Madison, Wisconsin, is comprised of ACO group practices and a partnership between a hospital and ACO professionals, with 701 physicians. It will serve Medicare beneficiaries in Wisconsin.

ProHealth Solutions, LLC, located in Waukesha, Wisconsin, is comprised of partnerships between hospitals and ACO professionals, with 697 physicians. It will serve Medicare beneficiaries in Wisconsin. 

---

[1] Source: Self-reported information from the Medicare Shared Savings Program Application for July 1, 2012 cycle

CMS PROPOSED RULE WOULD INCREASE PAYMENT TO FAMILY PHYSICIANS BY 7 PERCENT

FOR IMMEDIATE RELEASE                                Contact: CMS Media Relations Group

July 6, 2012                                                                                     (202) 690-6145

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would increase payments to family physicians by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.  The increase in payment to family practitioners is part of the proposed rule that would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013.  Under the MPFS, Medicare pays more than 1 million physicians and nonphysician practitioners that provide vital health services to Medicare beneficiaries. 

“Helping primary care doctors will help improve patient care and lower health care costs long term,” said CMS Acting Administrator, Marilyn B. Tavenner. 

The 7 percent increase for family physicians comes from a proposal that continues the Administration’s policies to promote high quality, patient-centered care.  For CY 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The proposed rule also asks for public comment on how Medicare can better recognize the range of services community physicians and practitioners provide as part of treating patients either through face-to-face services in the office or coordinating care outside the office when the patient does not see the physician.

As has been the case every year since CY 2002, CMS projects a significant reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) methodology due to the expiration of the adjustment made for CY 2012 in the statute.  For CY 2013, CMS projects a reduction of 27 percent and is required by law to include this reduction in these calculations. However, Congress has acted to avert the cuts every year since 2003.  The Administration is committed to fixing the SGR formula in a fiscally responsible way.

The proposed rule would also continue the careful implementation of the physician value-based payment modifier (Value Modifier) that was included in the Affordable Care Act by providing choices to physicians regarding how to participate.  The Value Modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs.  The law allows CMS to phase in the Value Modifier over three years from CY 2015 to CY 2017.  For the CY 2015 physician payment rates, the proposed rule would apply the Value Modifier to all groups of physician with 25 or more eligible professionals.  The proposed rule also provides an option for these groups to choose how the Value Modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS).  For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their Value Modifier at a 1.0 percent payment reduction.  For groups that wish to have their payment adjusted according to their performance on the value modifier, the rule proposes a system whereby groups with higher quality and lower costs would be paid more, and groups with lower quality and higher costs would be paid less. The performance period for the CY 2015 Value Modifier was established as CY 2013 in the MPFS Final Rule for CY 2012. 

The proposed rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity. The proposed rule proposes changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology.  The PQRS proposal includes simplified, lower burden options for reporting and the proposed rule aligns quality reporting across the various programs in support of the National Quality Strategy.  The proposed rule also addresses the next phase in a plan to enhance the Physician Compare Website to foster transparency and public reporting of certain information to give beneficiaries more information for purposes of choosing a physician.

The proposed rule also includes:

• A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system;
• A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
• A proposal to apply a multiple procedure payment reduction (MPPR) policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day;
• A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy, and speech language pathology services;
• A request for public comments on payment for advanced diagnostic molecular pathology services;
• A proposal to revise a regulation that only allows Medicare to pay for portable x-rays ordered by an MD or DO.  The revised regulations would allow Medicare to pay for portable x-ray services ordered physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law;
• A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by State law.  This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until Sep. 04, 2012, and will respond to them in a final rule with comment period to be issued by Nov. 1, 2012.
For more information, see: 
http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

Today's Datapoint

20% ... of physicians are in discussions to join or form ACOs, according to the 2012 National Physician Survey conducted by the little blue book and Sharecare.

Quote of the Day

The Supreme Court’s ruling that it was improperly coercive for the federal government to force states to expand Medicaid rolls or have federal funds withheld “truly breaks new ground. It’s the first time since the 1930s that the Supreme Court has invalidated a federal spending statute that gives money to states and attaches strings. A number of other federal spending programs that attach strings will now be attacked as coercive.”

— Harvard law professor Richard Fallon told The Washington Post.

2013 CMS Marketing Guidance Changes Disclaimers, Website Review, Star Ratings

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

By James Gutman, Managing Editor

June 21, 2012 Volume 18 Issue 12

Perhaps the best news for Medicare Advantage plans in the final CMS 2013 marketing guidance released June 6 is that the size of the guidance document is 120 pages versus 192 for the 2012 guidance. As the shrinkage may suggest, there are not a lot of new requirements for MA sponsors for the coming marketing season. But there are some changes, including in important areas such as disclaimers, time frames for actions to occur, and website reviews, along with a general toughening of rules regarding marketing on CMS’s star quality ratings.

The “biggest caution” consulting firm Gorman Health Group, LLC has regarding the guidelines, President Jeff Fox tells MAN, is that just because the number of pages shrunk substantially, this does not necessarily mean CMS eliminated requirements. In some cases, Fox notes, CMS instead only eliminated repetition or placed the requirements in other manual chapters or guidance documents instead of this new Chapter 3 in the Medicare Managed Care Manual.

Looking at the 2013 guidance overall, he says one significant change is in the area of disclaimers, such as when material is considered for purposes of enrollment versus just for information. Fox warns that disclaimers constitute the No. 1 reason MA marketing materials are declined by CMS. “Make sure you have the required language,” he says.

Another significant new requirement, according to Fox, is that for 2013 two of the three required outbound enrollment and verification (OEV) calls within 15 days of receipt of the application must be made within the first 10 days. These calls are done on enrollments obtained by both independent and employed agents/brokers to ensure that new members understand the plan’s rules. Fox points out that “the clock starts” the day the beneficiary and agent sign the enrollment, so if agents are very busy and don’t send in the enrollments right away, this can be a problem.

Also newly required is that the Multi-Language Insert containing information translated into several languages and offering free interpreter services for answering questions about plans must be sent with all Summary of Benefits and Annual Notice of Changes (ANOC) documents to members. Plans may incorporate this into those materials or have it as a separate document, but it no longer is required only when at least 5% of the sponsor’s plan benefit package service area has a given foreign language as its primary language. “Everybody has to have it,” Fox emphasizes.

Some of the changes are positive for plans, he notes. Under the 2013 guidelines, for example, says Fox, not all call-center scripts need to be filed with CMS. If the material involved is just informational, he explains, plans just need to maintain it and to produce it if asked during plan audits, but it doesn’t need to be transmitted on an ordinary basis.

Among the areas that have new regulations are ones that are relatively new and hot — including plan websites and the marketing of a plan’s star ratings. The section on websites, for example, Fox says, features a fundamental change. In the past, he recalls, if a plan filed required information for the website and CMS performed a random audit and found a problem, the plan could keep the section with the problem posted and, until the problem is resolved, just add a disclaimer that it is being fixed. Now CMS is saying that if there is an error, the plan must take down the entire section with the error until it is fixed, he says, adding, “This is kind of big.”

So too are some of the changes CMS is making on star-ratings marketing. The agency clearly is concerned about plans that trumpet their high ratings in a particular category of the star ratings and might leave the impression that this score is their overall star rating. So it is setting firm guidelines on how the ratings may and may not be used for marketing purposes.

Overall Star Ratings Must Be Included

“Plan sponsors may only reference the contract’s individual measures in conjunction with its overall performance rating in marketing materials,” the guidance states. “Plan sponsors may not use their star rating in a lower category or measure to imply a higher overall plan rating in their marketing materials than is actually the case.” Citing the example of a plan getting the top score of 5 in customer service promoting itself as a five-star plan when its overall plan rating is only two stars, CMS says, “Sponsors must use their star ratings in marketing materials in a manner that does not mislead beneficiaries into enrolling in plans based on inaccurate information.”

Even five-star plans, which now are allowed to market year-round and to use CMS’s gold-star icon on their marketing materials, are not immune from new requirements regarding that. CMS says, “The icon must be included in a way that is not misleading and makes it clear to the audience that the 5-star rating is for a specific contract(s), as applicable. Parent organizations with only one 5-star contract should not create materials in a way that implies all of its contracts achieved this rating.”

CMS is concerned that star ratings might be misconstrued by consumers, says Mary Kaye Thibert, a vice president at Gorman Health Group. While Thibert tells MAN she didn’t see plans seek to market individual star ratings rather than their overall ratings in the West, where she is based, she would have recommended that MA plans market both a specific major rating and the overall rating in situations where both are strong.

She acknowledges, though, that many Medicare beneficiaries still don’t understand the star ratings. If CMS educates consumers more about the ratings, this could change, she adds.

The most significant star-rating-related marketing guidelines change for 2013, according to Thibert, is a requirement that plans doing stars marketing update the ratings in their promotional materials within 15 days of receipt of the final 2013 ratings, instead of 30 days as previously.

The difficulty on this stems from the calendar: The final ratings last year were released Oct. 12, and product-specific marketing began Oct. 1. The problem, Thibert explains, is that many big plans have the star ratings included in large amounts of pre-collated marketing materials and now would have to rapidly change and replace the affected pages.

Linda Armstrong, executive vice president and health insurance practice leader at direct-marketing specialist DMW Worldwide, says this change in the guidance is manageable. It means DMW will recommend to its MA plan clients that they put anything related to their star ratings in either “buckslips” or personalized copy that can be changed quickly and inexpensively, she says.

A more significant issue for DMW in the guidelines, Armstrong tells MAN, is that television advertising “now appears to be a 45-day [review by CMS] submission.” She bases this conclusion on the lack of a reference as in the previous-year guidelines to TV ads as falling in the “file and use” submission category. By contrast, in the guidelines for 2012, CMS specifically said, “Television advertisements are File & Use documents.”

Because of that previous assurance, adds Armstrong, “we could concentrate on getting direct mail submitted and then work on TV later. Now, this will need to be a part of the 45-day crunch of submissions.”

View the final marketing guidelines at www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPartCMarketi...

States Could Cut Medicaid Rolls In 2014 As A Result Of Court Ruling

By Phil Galewitz

KHN Staff Writer

Jul 03, 2012

Starting in 2014, things could get worse for people in Medicaid.

Not only could some states opt out of increasing the number of adults in the government health insurance program for the poor as a result of the Supreme Court’s ruling, but they also could cut people now enrolled.

This wasn’t supposed to happen under President Barack Obama’s health law designed to expand coverage for 30 million Americans, in part by adding 17 million people to Medicaid.

But the impact of the high court’s ruling making the expansion voluntary is likely to be compounded by another provision in the law that the justices left intact: In 2014, states are no longer barred from making it harder for adults to qualify for Medicaid.

Experts worry those two developments taken together could spur some states to reduce the number of people covered.

States could throw some low-income adults “into a black hole with nowhere to turn for coverage," said Deborah Bachrach, who was New York’s Medicaid director until 2010 and now is special counsel at Manatt, Phelps & Phillips, a New York law firm.

As a hypothetical example, if Mississippi opted out of the 2014 expansion of Medicaid, poor childless adults would not gain coverage in that state. At the same time, the state could roll back eligibility for parents with children who are currently enrolled, reducing the number of participants in the program.

State officials have not talked about cutting Medicaid eligibility since the decision. But in the last several years, many have sought to reduce the cost of the program by cutting providers’ rates and contracting with private managed care companies, among other strategies.

"It’s a perfectly reasonable concern" that states might make it more difficult for adults to qualify, said Sara Rosenbaum, health policy professor at George Washington University.

Since 2009, when Congress approved the federal stimulus law, which included additional Medicaid funding, states have been prohibited from reducing eligibility or increasing the cost-sharing requirement for people enrolled in Medicaid. The health law extended that prohibition until 2014, when the expectation was that every state would adopt the Medicaid expansion under the law to give everyone under 133 percent of federal poverty level access to Medicaid.

But the high court struck down the penalty for states that did not expand, saying the threatened loss of their existing federal Medicaid dollars was "coercive."

Another way states might choose to minimize their costs is by shifting people who are eligible for federal subsidies for private insurance out of the Medicaid program and into new online markets created by the law. That saves states money because the federal government pays the entire cost of the subsidies -- unlike Medicaid, where states share in the costs.

The federal subsidies are available for those with incomes from 100 percent of the federal poverty level ($23,050 for family of four), to 400 percent ($92,000 for a family of four).

States would have an incentive, then, to set eligibility for Medicaid at 100 percent of the poverty level – rather than at the law’s 133 percent (about $31,000 for a family of four) -- to minimize their financial exposure.

Pushing people just over the poverty level into the federal subsidy program could be enticing for cash-strapped states that today share in the costs of Medicaid with the federal government, said Douglas Holtz-Eakin, president of the conservative American Action Forum and a former director of the Congressional Budget Office.

Since last week, Republican governors in at least seven states have indicated they would be unlikely to expand Medicaid even though the federal government will pay all the costs from 2014 to 2017 and at least 90 percent of the costs after that. States have until next year to decide on the expansion, and some are expected to negotiate their own terms with the Obama administration before signing on.

"This is going to be a lengthy dance between the states and federal government," Rosenbaum said.

http://www.kaiserhealthnews.org/Stories/2012/July/03/states-could-cut-medicaid-rolls-after-ruling.aspx

Ramp Up Support in the Senate

From the National Association of Health Underwriters ( http://www.nahu.org )

Thursday the U.S. Supreme Court ruled 5 to 4 to uphold the Patient Protection and Affordable Care Act (PPACA). The individual mandate requiring Americans buy health insurance was deemed constitutional in the ruling. Yet changes were made to the Medicaid provisions of the law.

Given today’s landmark ruling, it is more important than ever for NAHU members (and those who are involved in the sale and servicing of health insurance) to engage their senators in support for revising the Medical Loss Ratio (MLR).

S. 2288, a bill to remove broker compensation from the MLR calculation, introduced by Mary Landrieu (D-LA) and Johnny Isakson (R-GA) has 9 cosponsors!

We are asking you to take a few minutes to contact your senators through Operation Shout! and ask them to cosponsor S. 2288, which will remove agent and broker commissions from the MLR calculation.

Take Action - Click Here: http://capwiz.com/nahu/issues/alert/?alertid=61516036

If you are not a member of NAHU, visit http://www.nahu.org to learn more - and I would like to encourage you to become a member of the professional association which does its best to advocate for its members and their clients.