Banner Health Considers Pioneer ACO Contract

Arizona may be the home of the first pioneer ACO, if the state’s Banner Health accepts a contract presented by CMS this week. The largest health system in the state, Banner has a lot to gain from the early adopter ‘pioneer’ program.

In a statement describing massive funding cuts, Banner CEO Peter Fine explained the thought behind the move to ACO.

The traditional model of fee-for-service is gradually giving way to a collaborative model in which reimbursement is shared by hospitals, physicians and other providers based on the health management of defined populations…Doubtless, there will be those who will decry ACOs as a by-product of health-care reform and therefore unworthy of consideration. However, ACOs and similar collaborative models are moving forward whether health-care reform is implemented or not.

For Banner, the only point of concern was timing. “The issue before us now is that of timing. How fast can we bring new models of collaboration into existence?” Fine asked in his statement. As it turns out, it’s a question that many people are asking.

In a white paper available from the Robert Wood Johnson Foundation, authors Berenson RA and Burton RA explain that “…so far, the reception to CMS’ final regulations has been positive, but how many organizations will actually apply to CMS to be ACOs is another question.” The paper attempted to explain CMS’s motives for the ACO Pioneer program, and to establish a prediction on the widespread success of the program. FierceHealthcare summarizes:

How many and how fast will ACOs spread? CMS estimates 50 to 270 ACOs will sign up to participate, generating a net savings of $940 million during the first four years through Shared Savings, according to a recent report by the Urban Institute and the Robert Wood Johnson Foundation…

…According to the report, it's unclear if the Shared Savings Program and the earlier Pioneer ACO model are intended to test the ACO concept for large-scale implementation, to see whether it generates sustainable governmental savings, or to move as many providers as possible to ACOs to curb Medicare spending.

A few years will probably pass before we can come to any definitive conclusions on the program, but the Banner exercise at least demonstrates how much is at stake.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Final Rule Addresses ACO Criticism

At their first announcement, the Centers for Medicare and Medicaid Services’ rules for ACOs caused an uproar. Accountable Care Organizations will reward medical providers that meet certain quality of care requirements, but health professionals found the rules to be needlessly complicated, hard to follow, and unrealistic. CMS responded quickly, committing to rework and improve the rule set.

On October 20^th, the proposed changes, collectively called the final rule, released to public acclaim. CMS Administrator Dr. Donald Berwick told Kaiser Health News, “We have been able to fine tune and improve the rules for a range of stakeholders, providers and patients.” Across the board, health industry officials are praising CMS for the new rule changes, and it seems that these requirements will finally move toward improving the country’s health care.

FierceHealthCare.com put together a table outlining the changes CMS made. We have an excerpt below, or you can view the full table here.

Topic	Proposed rule	Final rule
Transition to risk in Track 1	ACOs offer two tracks. Track 1 would entail two years of one-sided shared savings; then participants would have to transition in third year to a performance-based risk, two-sided model of savings and losses.	ACOs still offer two tracks. Track 1 now removes two-sided risk.
Prospective vs. retrospective	Retrospective assignment based on primary care service use, with prospective identification of benchmark population	Preliminary prospective-assignment with beneficiaries identified quarterly, with final reconciliation after each performance year
Quality measures	65 measures in 5 domains	33 measures in 4 domains
Shared savings	One-sided risk model: Sharing begins at savings of 2 percent Two-sided risk model: Sharing on first dollar	Share on first dollar for all ACOs in both models once min. savings rate is achieved

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Medicare Annual Open Enrollment Begins Early

This year, CMS has announced an early launch for Open Enrollment, which will begin October 15^th, instead of the usual date of November 15^th. The enrollment will end on December 7^th. CMS made this change under hopes that it would improve the enrollment process for Medicare beneficiaries, according to the official press release.

This gives people with Medicare a full seven weeks to compare and make decisions, and ensures that they will have essential plan materials and membership cards in hand on January 1, 2012 when new coverage starts.

In the press release, CMS also made efforts to stress the importance of investigating and exploring plan options.

There'll be a wide range of health and drug plan options available across the country, including Original Medicare. Most people with Medicare can choose a "Part D" plan to help them pay for prescription drugs. And people who have chosen to enroll in a "Part C" Medicare Advantage plan for their basic health care services have the option of staying in that plan, choosing a different plan, or going back to the Original Medicare program. Plans can change from year to year, so these are important choices that should be made with care.

As usual, the organization is making a big push to promote information sources such as 1-800-MEDICARE and http://www.medicare.gov. We saw many efforts being made around this time last year to promote those educational channels, and it is certainly good to see them remaining a large part of CMS’s enrollment initiative.

 

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

News From The 2011 CMS Fall Conference

The CMS Fall Conference this year can be defined with one word: improvements. The conference was designed with a series of breakout sessions, each intended to give CMS experts the ability to hear questions, concerns, and criticisms from those of us in the industry. It wasn’t a one-way conversation, however, as the experts in attendance provided plenty of information and commentary.

As I have already said, CMS made a great effort to stress their initiatives for improving Medicare and Medicaid programs. These efforts will include:

• Valuable products
• Clear benefits
• Accurate communications
• Accurate benefits
• No tricks at educational events
• Regulation-consistent marketing
• Secret shopping
• A stricter policy on misleading print ads and marketing

On a more positive note, CMS experts were enthusiastic about Part C and Part D programs. They were quick to stress that existing programs were not bad, but that they could do more. These initiatives are all intended to lead to better care, healthier communities, and conformity to ACA law.

The other major point of discussion was the CMS star rating system. A perfect five-star rating can bring many advantages to a plan, including year-round marketing to beneficiaries turning 65. A beneficiary may join or switch to a five-star plan from an MA, MAPD, or PDP plan, barring a few limitations:

• Beneficiaries can only join a plan in their area.
• They can only enroll in a 2012 plan with a five star rating.
• A beneficiary can only use this process one time per year.
• If one moves from a plan with drug coverage to a five-star plan that does not have drug coverage, they lose that coverage and cannot return to their previous plan.

CMS warned plans that deliberately structuring themselves to maximize ratings would not be an effective tactic, and that if plans stay focused on overall quality of care, and appropriate care, their star rating will be good.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

The 2011 CMS Fall Conference

It's that time of year again! Halloween decorations are already for sale in malls and grocery stores, the kids are back in school, and the words on everyone's lips are 'Prescription Drug Marketing Compliance."

That last bit may be a bit of an exaggeration, but nevertheless, it is time for the CMS 2011 Medicare Advantage and Prescription Drug Plan Fall Enrollment, Marketing and Compliance Conference. As usual, I, Pamela Argeris, will be attending on behalf of Merrill Corporation. This year's conference promises to be interesting, with plenty of topics that need stronger clarification, combined with the fact that a Presidential election year will soon be upon us:

• New Annual Enrollment Period and other related Enrollment Period’s
• Medicare Advantage Disenrollment Period/ 5 Star (SEP) Special Enrollment Period
• Marketing and Enrollment
• Part D IRMAA/ Reinstatement for Good Cause
• End of Year Transition and Systems Activity
• Quality Improvement Strategy for the Medicare Advantage Program
• Changes in the Enrollment Chapters (regulations)

The conference  begins on September 20th, and will also be broadcast live on the web, for registered attendees that cannot make it to the conference. There are also planned break-out sessions covering HPMS Training, Retroactive Processing Contractor, and MARx Reports. These sessions will give CMS experts the opportunity to listen to concerns and questions about these systems.

The goal of the Fall conference is to ensure that all sponsors and marketers working within the health and pharmaceutical fields remain up-to-date on the most recent changes to prescription drug marketing compliance.

The CMS Fall Conference is always a great source of information, and Merrill Corporation looks forward to the opportunity to better perfect our health industry services.
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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.