(ACO) regulations - American Society of Anesthesiologists

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CMS-1345-P 50 consider whether it would be appropriate to expand the list of entities eligible to participate in the Shared Savings Program, either in the final rule or in future rulemaking, if we determine that it is feasible and consistent with the requirements of the program for more entities to participate as ACOs. In the interim, and until such time as FQHCs and RHCs would be eligible to form ACOs or have their patients assigned to an ACO, we are also proposing to provide an incentive for ACOs to include RHCs and FQHCs as ACO participants, by allowing ACOs that include such entities to receive a higher percentage of any shared savings under the program. We believe that this proposal to encourage participation by RHCs and FQHCs in ACOs is appropriate in light of the special role that these entities play in the health care delivery system, especially in providing care to otherwise underserved and vulnerable populations. We discuss how this proposal affects the determination of shared savings under the program in section II.F. of this proposed rule. 2. Legal Structure and Governance Section 1899(b)(2)(C) of the Act requires an ACO to "have a formal legal structure that would allow the organization to receive and distribute payments for shared savings" to "participating providers of services and suppliers." As previously noted, section 1899(b)(1) of the Act also requires ACO participants to have a "mechanism for shared governance" in order to participate in the program. Operationally, an ACO's legal structure must provide both the basis for its shared governance as well as the mechanism for it to receive and distribute shared savings payments to ACO participants and providers/suppliers. a. Legal Entity
CMS-1345-P 51 The ACO's legal entity may be structured in a variety of ways, including as a corporation, partnership, limited liability company, foundation, or other entity permitted by State law. As discussed previously in section II. B. of this proposed rule, and consistent with section 1899(b)(1)(A)-(D) of the Act, certain specified groups of providers of services and suppliers who have a mechanism of shared governance may be eligible to participate as ACOs in the Shared Savings Program. In addition to the groups specifically identified in the statute, we are proposing to use the Secretary's discretion under section 1899(b)(1)(E) of the Act to expand the list of eligible groups of providers and suppliers that may participate in the Shared Savings rogram. Specifically, we are proposing that ACOs may incorporate other groups of Medicare enrolled providers and suppliers, many of whom would not be able to form ACOs and participate in the program independently. As described previously, each of the Medicare-enrolled providers and suppliers that join together to form an ACO is identified by their Medicare-enrolled TIN and is referred to herein as an ACO participant. Regardless of whether an ACO participant is able to meet the eligibility criteria for participation in the Shared Savings Program independently or must join with others in order to meet criteria, we propose that the ACO must demonstrate a mechanism of shared governance that provides all ACO participants with an appropriate proportionate control over the ACO's decision making process. In response to the request for information (RFI) that appeared in the November 17, 2010 Federal Register (75 FR 70165), we received comments regarding the need for us to remain flexible when defining the required legal structure to allow for a variety of structural options. For example, commenters noted that we should permit
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Page 3 and 4: CMS-1345-P 3 Centers for Medicare &
Page 5 and 6: CMS-1345-P 5 C. Overview and Intent
Page 7 and 8: CMS-1345-P 7 7. Aligning ACO Qualit
Page 9 and 10: CMS-1345-P 9 CCNC Community Care of
Page 11 and 12: CMS-1345-P 11 SSN TIN Social Securi
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Page 15 and 16: CMS-1345-P 15 and efficient service
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Page 21 and 22: CMS-1345-P 21 Section 1899(d)(3) of
Page 23 and 24: CMS-1345-P 23 Section 1899 (i) of t
Page 25 and 26: CMS-1345-P 25 • An ACO will manag
Page 27 and 28: CMS-1345-P 27 providers participati
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Page 33 and 34: CMS-1345-P 33 personal physicians;
Page 35 and 36: CMS-1345-P 35 • Experience with n
Page 37 and 38: CMS-1345-P 37 when looking at the e
Page 39 and 40: CMS-1345-P 39 Medicare FFS benefici
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Page 43 and 44: CMS-1345-P 43 Since the statute req
Page 45 and 46: CMS-1345-P 45 For FQHCs and RHCs, t
Page 47 and 48: CMS-1345-P 47 individual practition
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Page 53 and 54: CMS-1345-P 53 We note that by propo
Page 55 and 56: CMS-1345-P 55 and administrative sy
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Page 63 and 64: CMS-1345-P 63 • Clinical manageme
Page 65 and 66: CMS-1345-P 65 participants and ACO
Page 67 and 68: CMS-1345-P 67 Section 1899(b)(2)(A)
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Page 73 and 74: CMS-1345-P 73 Thus, we considered w
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Page 79 and 80: CMS-1345-P 79 b. Processes to Promo
Page 81 and 82: CMS-1345-P 81 • Telehealth. • T
Page 83 and 84: CMS-1345-P 83 centeredness that is
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Page 87 and 88: CMS-1345-P 87 We are soliciting com
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Page 91 and 92: CMS-1345-P 91 panel. Such a proposa
Page 93 and 94: CMS-1345-P 93 addressing disparitie
Page 95 and 96: CMS-1345-P 95 Individualized plans
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Page 99 and 100: CMS-1345-P 99 a. Compliance Plans W
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CMS-1345-P 101 generated by ACO par
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CMS-1345-P 103 C. Establishing the
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CMS-1345-P 105 After evaluating the
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CMS-1345-P 107 when the final payme
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CMS-1345-P 109 performance of ACO p
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CMS-1345-P 111 cost-effectiveness o
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CMS-1345-P 113 they identify priori
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CMS-1345-P 115 generally bars the d
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CMS-1345-P 117 acting on behalf of
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CMS-1345-P 119 previous year's hist
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CMS-1345-P 121 providers/suppliers.
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CMS-1345-P 123 permitted under the
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CMS-1345-P 125 and the claim paymen
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CMS-1345-P 127 measurement activiti
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CMS-1345-P 129 beneficiary choice:
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CMS-1345-P 131 promote trust and pe
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CMS-1345-P 133 beneficiaries. We an
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CMS-1345-P 135 ensure that ACOs und
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CMS-1345-P 137 eligibility since th
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CMS-1345-P 139 or to providers or s
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CMS-1345-P 141 ACO and the eligibil
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CMS-1345-P 143 From a technical, op
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CMS-1345-P 145 beneficiaries would
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CMS-1345-P 147 associated with thos
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CMS-1345-P 149 pediatric medicine,"
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CMS-1345-P 151 care services" on th
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CMS-1345-P 153 better address the d
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CMS-1345-P 155 assignment from year
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CMS-1345-P 157 appropriate safeguar
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CMS-1345-P 159 ACO only when he or
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CMS-1345-P 161 We propose to implem
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CMS-1345-P 163 quality and shared s
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CMS-1345-P 165 chosen. We seek comm
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CMS-1345-P 167 measures to assess t
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CMS-1345-P 169 • To the extent pr
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CMS-1345-P 171 data collection and
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CMS-1345-P 173 improving ACO qualit
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CMS-1345-P 175 Domain Measure Title
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CMS-1345-P 187 43. At Risk Populati
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CMS-1345-P 189 50. At Risk Populati
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CMS-1345-P 195 Information on Physi
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CMS-1345-P 197 associated with clai
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CMS-1345-P 199 be required to popul
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CMS-1345-P 201 as that term is defi
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CMS-1345-P 203 Table 2: Five Measur
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CMS-1345-P 205 sided shared savings
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CMS-1345-P 207 Table 4: Total Point
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CMS-1345-P 209 Medicare program. Fu
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CMS-1345-P 211 for the first perfor
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CMS-1345-P 213 of quality acknowled
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CMS-1345-P 215 (Option 1) but using
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CMS-1345-P 217 ACO would qualify fo
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CMS-1345-P 219 future rulemaking. W
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CMS-1345-P 221 proposing greater al
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CMS-1345-P 223 6. Public Reporting
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CMS-1345-P 225 efficiency, effectiv
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CMS-1345-P 227 this information ava
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CMS-1345-P 229 Specifically, we see
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CMS-1345-P 231 We considered severa
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CMS-1345-P 233 Track 2: More experi
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CMS-1345-P 235 determinations about
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CMS-1345-P 237 beneficiaries during
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CMS-1345-P 239 truncate an assigned
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CMS-1345-P 241 the demonstration wh
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CMS-1345-P 243 We seek comments abo
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CMS-1345-P 245 Of these two methods
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CMS-1345-P 247 other factor could b
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CMS-1345-P 249 Capitation Rates, Pa
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CMS-1345-P 251 A model that uses be
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CMS-1345-P 253 option to audit ACOs
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CMS-1345-P 255 Thus, we are not pro
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CMS-1345-P 257 subsequently receive
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CMS-1345-P 259 This benchmark is su
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CMS-1345-P 261 nationwide under the
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CMS-1345-P 263 benchmark based on t
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CMS-1345-P 265 upon the number of M
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CMS-1345-P 267 beneficiaries. In re
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CMS-1345-P 269 and share in savings
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CMS-1345-P 271 a result of normal y
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CMS-1345-P 273 • 50 percent or mo
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CMS-1345-P 275 • Among older adul
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CMS-1345-P 277 of dual eligible ben
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CMS-1345-P 279 they incur shareable
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CMS-1345-P 281 for the Medicare pro
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CMS-1345-P 283 and efficiency of ca
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CMS-1345-P 285 have also suggested
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CMS-1345-P 287 providers' willingne
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CMS-1345-P 289 expect to consider i
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CMS-1345-P 291 two years under the
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CMS-1345-P 293 Design Element Minim
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CMS-1345-P 295 performance) under t
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CMS-1345-P 297 For purposes of the
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CMS-1345-P 299 proposed that for th
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CMS-1345-P 301 For example, a two-s
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CMS-1345-P 303 depends on the ACO's
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CMS-1345-P 305 have solicited comme
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CMS-1345-P 307 the ACO's repayment
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CMS-1345-P 309 the growth in Medica
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CMS-1345-P 311 relied upon by us in
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CMS-1345-P 313 requirements not set
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CMS-1345-P 315 entity is in an arra
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CMS-1345-P 317 disease) or benefici
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CMS-1345-P 319 information. If the
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CMS-1345-P 321 ● Failure to compl
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CMS-1345-P 323 harm to beneficiarie
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CMS-1345-P 325 determinations would
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CMS-1345-P 327 Shared Savings Progr
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CMS-1345-P 329 CMS and OIG have joi
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CMS-1345-P 331 The Antitrust Policy
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CMS-1345-P 333 previously. Such an
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CMS-1345-P 335 protects beneficiary
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CMS-1345-P 337 both Medicare benefi
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CMS-1345-P 339 J. Overlap with Othe
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CMS-1345-P 341 CMS shared savings p
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CMS-1345-P 343 Shared Savings Progr
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CMS-1345-P 345 improve the Shared S
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CMS-1345-P 347 V. Regulatory Impact
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CMS-1345-P 349 The Shared Savings P
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CMS-1345-P 351 ACOs work to improve
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CMS-1345-P 353 presumably provide a
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CMS-1345-P 355 • Number of partic
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CMS-1345-P 357 distribution. With t
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CMS-1345-P 359 c. Further Considera
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CMS-1345-P 361 More specifically, w
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CMS-1345-P 363 program and uncertai
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CMS-1345-P 365 Savings Program at 7
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CMS-1345-P 367 ACO-attributed claim
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CMS-1345-P 369 Category Costs COSTS
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CMS-1345-P 371 For the reasons set
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CMS-1345-P 373 (2) Program requirem
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CMS-1345-P 375 Act. Hospital means
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CMS-1345-P 377 meet the minimum qua
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CMS-1345-P 379 (C) Begin to operate
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CMS-1345-P 381 (D) The civil moneta
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CMS-1345-P 383 prior to the start o
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CMS-1345-P 385 for populations, and
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CMS-1345-P 387 monitoring and evalu
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CMS-1345-P 389 (i) It plans to use
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CMS-1345-P 391 (1) Have a beneficia
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CMS-1345-P 393 who were an ACO part
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CMS-1345-P 395 amount for the patie
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CMS-1345-P 397 under §425.7(b). An
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CMS-1345-P 399 (ii) To be responsib
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CMS-1345-P 401 §425.8 ACO quality
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CMS-1345-P 403 (2) CMS scores indiv
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CMS-1345-P 405 (a) Monitoring of AC
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CMS-1345-P 407 required measure dat
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CMS-1345-P 409 (5) The procedures e
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CMS-1345-P 411 demonstrate in its a
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CMS-1345-P 413 days of the notice o
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CMS-1345-P 415 original notice of d
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CMS-1345-P 417 (c) Notwithstanding
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CMS-1345-P 419 (ii) Quality perform
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CMS-1345-P 421 (i) The beneficiary
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CMS-1345-P 423 terminated from the
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CMS-1345-P 425 inclusion of additio
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CMS-1345-P 427 individuals, better
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CMS-1345-P 04/07/2011] [FR Doc. 201
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