Accountable Care Network FAQ

Answers for providers interested in the UC San Diego Health Medicare Shared Savings Program ACO

“An ACO is composed of groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated, high quality care to their Medicare fee-for-service beneficiaries. The Shared Savings Program rewards an ACO that improves the quality and cost efficiency of health care.”
– Centers for Medicare and Medicaid Services (CMS)

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Why has UC San Diego Health formed an ACO?

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.

How does the MSSP ACO relate to MACRA?

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:

Merit Based Incentive Payment System (MIPS); or
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.

What type of ACO is UC San Diego Health Accountable Care Network?

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.

Why should I consider participating in UC San Diego Health Accountable Care Network?

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.

Can I participate in multiple ACOs and / or CMS programs?

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

Is a provider required to be in UC San Diego Health Affiliated Network (i.e., clinically integrated network) in order to be in UC San Diego Health Accountable Care Network (ACO)?

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.

Are all clinicians who bill Medicare under a single TIN required to participate in the ACO, or can some participate while others do not?

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.

How do I switch from my current MSSP ACO to UC San Diego Health Accountable Care Network?

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.

How will shared savings be distributed?

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.

How are beneficiaries assigned to an ACO?

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.

How will this impact Medicare FFS payments to individual practices or physicians?

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.

What is the impact to Medicare beneficiaries if a provider chooses to participate in a Medicare Shared Savings Program ACO?

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.

MACRA | Evolving Payer Models: CMS Quality Payment Program

What is the Quality Payment Program?

In April 2015, Congress repealed the SGR (sustainable growth rate) formula that determined Medicare physician fees, replacing it with legislation called MACRA (Medicare Access and CHIP Reauthorization Act of 2015).

This landmark bipartisan legislation advances a forward-looking, coordinated framework for healthcare providers to successfully take part in the CMS Quality Payment Program (QPP) that rewards value and outcomes in one of two ways:

Alternative Payment Model (APM)
The Merit-Based Incentive Payment System (MIPS)

Who is in the Quality Payment Program?

Resources

Find our MACRA Readiness Assessment and more detailed information on MIPS categories for payment adjustments at Provider Resources.

The QPP policy will reform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire healthcare delivery system.

You can choose how you want to participate in the QPP based on your practice size, specialty, location or patient population. You’re a part of the QPP if you bill Medicare more than $30,000 a year AND provide care for more than 100 Medicare patients a year AND are a:

Physician
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist

What is APM (Alternative Payment Models)?

A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care. CMS is constantly developing new payment and service delivery models to encourage this mindset. One of those models is the Medicare Shared Savings Program (MSSP).

What is aAPM (Advanced Alternative Payment Models)?

For the 2017 performance year, you may qualify as an aAPM if you meet all 3 requirements below:

Use a certified Electronic Health Record (EHR)
Currently report quality measures comparable to those used in MIPS
You are in a medical home model OR bear more than a nominal amount of financial risk

What is aAPM (Advanced Alternative Payment Models)?

For the 2017 performance year, you may qualify as an aAPM if you meet all 3 requirements below:

Use a certified Electronic Health Record (EHR)
Currently report quality measures comparable to those used in MIPS
You are in a medical home model OR bear more than a nominal amount of financial risk

For the 2017 performance year, the following models are Advanced APMs:

Comprehensive End-State Renal Disease Care Model (Two-Sided Risk Arrangements)
Comprehensive Primary Care Plus (CPC+)
Next Generation ACO Model
Shared Savings Program Track 2
Shared Savings Program Track 3
Oncology Care Model (Two-Sided Risk Arrangement)

Additional aAPM models for 2018:

ACO Track 1+ (*Our ACO model.)
New Voluntary Bundled Payment Model
Comprehensive Care for Joint Replacement Payment Model
Advancing Care Coordination through Episode Payment Models Track 1

What is MIPS (Merit-Based Incentive Payment System)?

In MIPS, you can earn a payment adjustment based on evidence-based and practice-specific quality data. MIPS is the category that will apply to most physicians:

Moves Medicare Part B clinicians to a performance-based payment system
Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
Reporting standards align with Advanced APMs wherever possible

Key Takeaway

Positive adjustments are based on the performance data of the performance information submitted, not the amount of information or length-of-time submitted. You can submit 90 days of information with great quality and receive a higher percentage than someone who submitted all year with acceptable quality.

Potential Financial Rewards

Although MACRA creates separate paths for payments under the Medicare Physician Fee Schedule (PFS), these paths are in addition to, not in replacement of, the PFS.

MACRA replaced SGR with a schedule that will increase baseline Medicare Part B payments by 0.5% per year until 2019. The first payment adjustments will be based on performance year 2017 and will reflect in your 2019 Medicare payments.

If you participate in an Advanced APM, you will receive a + payment adjustment of 5% every year, beginning in 2019.

PQRS Payment Reminder: PQRS will be referred to as a “legacy program.” The last performance year of this program was 2016. If you participated this last year, your payment adjustment will take place in 2018. As a reminder, this is not associated with your 2018 MIPS performance.

Novel Coronavirus (COVID-19) Information

Accountable Care Network FAQ

MACRA | Evolving Payer Models: CMS Quality Payment Program

Resources

Key Takeaway

Potential Financial Rewards