Accountable Care Network FAQ

UC San Diego Health formed an MSSP ACO to proactively respond to federal initiatives by CMS aimed at coordinating patient care to reduce system waste and achieve better patient outcomes. By forming a MSSP ACO, UC San Diego Health and participating providers are embracing innovative CMS payment models that reward efficient quality care.

The Medicare Access CHIP Reauthorization Act (MACRA) changes the way Medicare pays providers. MACRA repeals the Sustainable Growth Rate formula, streamlining multiple quality reporting programs into the newly formed Quality Payment Program (QPP), and rewarding value over volume.

Eligible clinicians under MACRA can participate in one of two payment paths:

1. Merit Based Incentive Payment System (MIPS); or
2. Advanced Alternative Payment Models (A-APMs)

Most Medicare Part B clinicians will be subject to MIPS. Under MIPS, providers will receive adjustments to their Medicare fee-for-service reimbursement based on a composite performance score measuring i) quality, ii) resource use (cost), iii) clinical practice improvement activities, and iv) advancing care information.

CMS incentivizes providers to participate in Advanced APMs, the alternative to payment under MIPS. Providers who participate in Advanced APMs can avoid MIPS and receive an annual 5 percent bonus on top of their Medicare Part B reimbursement. CMS applies thresholds to Advanced APMs to determine if the model is a qualifying participant. If the Advanced APM meets the thresholds, then the participants are excluded from MIPS and eligible for the annual 5 percent bonus.

Advanced APMs under MACRA include: MSSP ACO Tracks 1+, 2 and 3; Next Generation ACO Model; Comprehensive ESRD Care Model; Oncology Care Model; and Comprehensive Primary Care Plus Model. Read more about MACRA.

UC San Diego Health Accountable Care Network is an MSSP Track 1+ ACO Model. This is a newly formed MSSP ACO model under MACRA that incorporates lower downside risk than in MSSP ACO Tracks 2 or 3.

UC San Diego Health Accountable Care Network is a MSSP Track 1+ ACO, which is an Advanced APM. Participation in a qualifying ACO allows providers to forgo MIPS and receive an annual 5 percent bonus over Medicare Part B reimbursement.

Participants have the opportunity to receive shared savings from the ACO as the network demonstrates its ability to lower health care costs while meeting CMS quality standards.

UC San Diego Health shelters participants from downside risk for the first 3-year agreement period.

Because the ACO is a Track 1+ model, participants in UC San Diego Health Accountable Care Network benefit from prospective — rather than retrospective — beneficiary assignment for required reporting and financial reconciliation. That means that ACO participants know which Medicare patients are assigned to the population being cared for in the ACO.

Alignment with UC San Diego Health Accountable Care Network provides practices the opportunity to take advantage of several benefits, including full access to the Epic electronic health record and information systems integration, collaboration with UC San Diego Health specialty providers, a shared network infrastructure for care coordination and network administration, and a partner through the evolution of health care regulations.

Each taxpayer identification number or CMS Certification Number (CCN) billing Medicare for primary care services (as defined in the MSSP regulations at §425.20) must be exclusive to one ACO’s certified list of ACO participants. Exclusivity in UC San Diego Accountable Care Network only applies to Medicare FFS and does not preclude you or your practice from participating in other IPA or payer network arrangements. According to CMS, the following provider types must be exclusive to a single ACO:

• Addiction medicine
• Cardiology
• Endocrinology
• Geriatric psychiatry
• Gynecology/oncology
• Hematology
• Hematology/oncology
• Medical oncology
• Multispecialty clinic or group practice
• Nephrology
• Neurology
• Neuropsychiatry
• Osteopathic manipulative medicine
• Obstetrics/gynecology
• Physical medicine and rehabilitation
• Preventive medicine
• Primary care (e.g., internal medicine, general practice, family practice, geriatric medicine, or pediatric medicine)
• Psychiatry
• Pulmonary disease
• Sports medicine

No – although we do encourage all ACO participants to explore the many benefits and opportunities of collaborating with UC San Diego Health through the Physician Network including a vast array of commercial health plan arrangements. Conversely, not all Physician Network affiliates are required to participate in UC San Diego Health Accountable Care Network. Please contact Duncan Campbell, Chief Operations Officer, for more information about the Physician Network; physiciannetwork@ucsd.edu or 858-249-0280.

Medicare requires a list of ACO participant TINs in order to attribute a given provider, practice, or hospital to an ACO. Therefore, CMS requires all providers who bill Medicare under a single TIN to agree to participate in the ACO.

If you currently participate in another Medicare Shared Savings Program ACO and would like assistance with the process of transitioning to the UC San Diego Health ACO, our staff can guide you through the required steps. Note that your practice is responsible for completing the close-out process when terminating your existing MSSP ACO participation agreement, including furnishing data necessary for the annual assessment of the ACO’s quality of care. To be added to the interest list for 2019 please contact Duncan Campbell at 858-249-0280.

The UC San Diego Health ACO will reserve 40% of shared savings for reinvestment in the ACO and distribute the remaining 60% to ACO participant providers. Shared savings reserved for ACO reinvestment will be used to fund administrative and operational expenses such as implementation of a single Electronic Medical Record across the ACO and additional resources for the centralized care management team.

Beneficiaries (patients on Medicare) are assigned to UC San Diego Accountable Care Network if they receive the plurality of their primary care services from PCPs (physicians or non-physician practitioners) with our ACO.

Providers continue to submit claims to Medicare under their existing Tax ID and NPI numbers, and Medicare reimburses on a fee-for-service basis as they have in the past. For ACO participants, CMS  provides routine reporting for assigned beneficiaries including information on utilization, cost, and quality to UC San Diego Health to determine performance against the established benchmark. UC San Diego Health will disseminate the data throughout the performance year and offer feedback on various measures to assist in the effort of enhancing performance and achieving savings.

Fee-for-service Medicare beneficiaries treated by providers who are participating in a Medicare Shared Savings Program ACO maintain all of their Medicare rights, including the right to choose any doctors and providers that accept Medicare. Whether a provider chooses to participate in an ACO or not, their existing Fee-for-Service Medicare patients may continue to see them.