Money Money, Who’s Got The Money?

 

Most of us know where the money is going, and it’s not to physicians or providers. There is much money to be made and had in our health system, whether it becomes socialized, nationalized or universally paid.  Universal payor? It’s your wallet. What’s left? Not much.

Insurance companies are doubling down  to hedge their bets.

Health insurance companies bitterly opposed the health care reform law but, as the merger between Aetna and Coventry Health Care announced Monday shows, the industry knows there's still money to be made.

The $5.6 billion Aetna-Coventry Health Care merger is the biggest in the health care sector since President Barack Obama enacted the reform law in March 2010. The deal will give Aetna, the third-largest health insurer in the U.S., a big increase in Medicare and Medicaid customers, including poor elderly people on both programs, and in the number of people who buy insurance on their own or get coverage from small businesses. Aetna will gain 5 million new customers when the merger is complete and stands to get even more in the near future.

"You've got an arms race going on in health care," said Robert Laszewski, a health care consultant and president of Health Policy and Strategy Associates in Alexandria, Va. Laszewski said health insurance companies, hospitals and other players are merging into bigger entities in hopes of restraining their own costs and grabbing larger shares of the markets as they are reshaped by health care reform. What the Aetna-Coventry Health Care merger won't do, at least in the short term, is lower anyone's health insurance premiums, he said.

The health insurance industry is undergoing a transformation as a result of the health care reform law, which the Supreme Court upheld in June. Twenty-five million people will buy health insurance on the law's regulated "exchange" marketplaces in the states, according to the Congressional Budget Office. Many of those small businesses and people who don't receive health benefits from their jobs will get federal tax credits. Medicaid will also add 11 million poor people and states are expected to contract with private health insurance companies to cover them.

Huffington Post expands on this post.  It’s worth reading….Health Insurance companies, like the American Medical Association and others did the ‘FLIP-FLOP’ at the last minute, they saw where your money is going….

                                      

 

Technorati Tags: health reform law,mergers,aetna,coventry health,obamacare,ppaca,medicare budget,medicaid

Sunday Morning Brunch Topic, Is PPACA’s Demise Pending?

 

Another Elephant in The Room……summer edition.

President Obama’s dream team’s health reform law may becoming unhinged as more people read the law (thank you, Nancy Pelosi) If you have a week of spare time, you can read it also.

It shouldn’t take a panel of experts, such as healthcare executives, supreme court justices or ordinary citizens to read a document that encompasses their health and lives.

Written in verse similar to a ‘bible’ it states  multiple times that “the Secretary of Health and Human Services shall………”

 

GOP presidential candidate Mitt Romney, running mate Paul Ryan, and other Republicans are stressing $716 billion in cuts to Medicare that are part of President Obama's health care plan.

The $716 billion in cuts are aimed not at Medicare recipients, but at health care providers, such as hospitals and medical device makers; they also target what the administration calls waste and inefficiency in Medicare. 

Meanwhile, speaking in Florida -- where the Medicare issue is particularly resonant -- Ryan told a group of senior citizens that Obama's plan "raids $716 billion from the Medicare program to pay for the Obama care program."

Ryan said the cuts are hurting nursing homes and Medicare Advantage insurance plans, and that "Medicare should not be used as a piggy bank for Obama care."

Ryan’ plan includes a voucher system for private care, the details of which were not explained, although it has been claimed it would increase the cost of care by $6400/Medicare recipient.

Obama’s plan calls for reducing payments to nursing homes and providers amount to $ 716 billion over ten years.  Obama claims that Romney’s plan would shorten the life of Medicare by ten years and end Medicare as we know it, because of the voucher system Romney and Ryan propose.

While there is some substance to these arguments and which deserve an open, transparent and public debate, it skirts the real issues of why Obamacare is poorly constructed.

The public debate has been superficial and couched not only in political terms, but fundamental issues of the form of government our Republic proposes to represent.

 

Technorati Tags: ppaca,obamacare,romney,paul ryan,medicare,repeal,repeal obamacare,medicare budget,nursing homes,providers,voucher,republicans,democrats,health reform law,nancy pelosi,supreme court,scotus

No Hospital Left Behind !

 

Is health care going to follow along the failed path of Education in the United States?

More than 2,000 hospitals — including some nationally recognized ones — will be penalized by the government starting in October because many of their patients are readmitted soon after discharge, new records show.

Together, these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying health care providers based on the quality of care they provide. One proposed measure is the rate of readmission.

With nearly one in five Medicare patients returning to the hospital within a month of discharge, the government considers readmissions a prime symptom of an overly expensive and uncoordinated health system.

Nearly 2 million Medicare beneficiaries are readmitted within 30 days of release each year, costing Medicare $17.5 billion in additional hospital bills. The national average readmission rate has remained steady at slightly above 19 percent for several years, even as many hospitals have worked harder to lower theirs.

These results reported by The Happy Hospitalist who also blogs and specializes in 'in patient hospital medicine".The report is in Kaiser Health News.

The penalties, authorized by the 2010 health care law, are part of a multipronged effort by Medicare to use its financial muscle to force improvements in hospital quality. In a few months, hospitals also will be penalized or rewarded based on how well they adhere to basic standards of care and how patients rated their experiences. Overall, Medicare has decided to penalize around two-thirds of the hospitals whose readmission rates it evaluated, the records show.

Kaiser Health News analysis of the records shows.  Hospitals that treat the most low-income patients will be hit particularly hard.

A total of 278 hospitals nationally will lose the maximum amount allowed under the health care law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked institutions, including Hackensack University Medical Center in New Jersey, North Shore University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a teaching hospital of Harvard Medical School

Most of these teaching hospitals treat  r uninsured patients on Medi-caid programs or other public safety net systems. Outpatient services are often very restricted, or unfunded. The patients have an increased rate of chronic illness which are more advanced in the first place since these patients do not get admitted until their disease is well advanced. Their care must be maximized prior to discharge, since their support  system is fragile or even not existent. This requires longer hospital stays, (which offsets the reduced re- admission rate)

"A lot of places have put in a lot of work and not seen improvement," said Dr. Kenneth Sands, senior vice president for quality at Beth Israel. "It is not completely understood what goes into an institution having a high readmission rate and what goes into improving" it.

Sands noted that Beth Israel, like several other hospitals with high readmission rates, also has unusually low mortality rates for its patients, which he says may reflect that the hospital does a good job at swiftly getting ailing patients back and preventing deaths.

Data for readmission rates are available in PDF or CSV files.

Atul Grover, chief public policy officer for the Association of American Medical Colleges, called Medicare’s new penalties "a total disregard for underserved patients and the hospitals that care for them." Blair Childs, an executive at the Premier healthcare alliance of hospitals, said: "It’s really ironic that you penalize the hospitals that need the funds to manage a particularly difficult population."

Does this sound familiar....??

Perhaps a wiser more prudent decision would be to implement this as a pilot program with regional distribution accordingly.

 

 

 

 

http://feeds.feedburner.com/blogspot/rWIA

A Critical Need. The System needs CPR

 

The passage of the Patient’s Protection and Affordable Act may be a mandate with an empty  promise.  Although it sets forth a detailed plan to build a new health insurance system, it does not address many issues in an orderly fashion. 

In fact the majority of physicians recognize and espouse the observation that the law will make the system worse.  It has been designed for political expediency to deliver visible benefits to expand access to healthcare, remove pre-existing barrier to coverage, and other highly visible benefits that are front-end loaded which will drive up costs, not decrease them.

One system cannot solve the multitude of challenges which are quite diverse between communities such as New York, Chicago, Los Angeles, rural cities such as Indio, California, Desert Hot Springs, California, Atlanta, Georgia or Oglethorpe GA.

A study that is often quoted is the “Dartmouth Study” of utilization and costs of a community such as McAllen Texas and  Portland Maine or Madison, WI or Mason City Iowa.  Statistics do not lie, but can be very deceiving when comparing such radically different demographics and diverse cultures.

Our community in the Inland Empire region of Southern California  combines a multi-cultural population, a high rate of unemployment (one of the highest in the  nation) and uninsured or medi-caid eligibles.  Riverside County and San Bernadino Counties are large, as large as some of the smallest states in the east. The western portions of both counties are metropolitan and the eastern portions rural, much like many states such as Maryland, New York and Georgia. This is not a unique problem in most states.             .

 

sy

 

Technorati Tags: aco,ppaca,health insurance,health train express,ucr,healthreform,medical school,physician shortage

Health Train at the Olympics 2012

 

Most of us have been watching the Olympics from London. It’s amazing  how records keep being broken.  Is it about more information about physiology, nutrition, and hopefully not  ‘doping’.  The medal winners seem to be getting younger and younger. ..why is that ?

As you may  be sitting on your couch or favorite chair some of you my increase your heart rate by that bag of popcorn, chips, cookies and milk, or that fast food brought home on the way from home.

Since studies have shown that 55% of us hold a smartphone in one hand while surfing the TV channels you want to look at all the new health mobile apps for exercise, and monitoring the state of your health and wellness.

Health Care IT: 2012 Olympics Shines Spotlight on Mobile Health and Fitness Apps

By Brian T. Horowitz on 2012-08-02

The Olympics are truly a great motivational event for young and older adults. Physical fitness is encouraged as a social event.

We hope your days are full of feel good summer fun! Those Olympians sure know how to play hard, so as the Olympic Games race full speed ahead, let's capture some of the athletes' positive energy and be inspired to live healthier today. Luckily, over 13,000 compassionate Medical Experts on HealthTap are always there to help you with your health questions, so ask away, and you'll learn ways you can feel better one day at a time. Wishing you all the best for a healthy week!

Here is a great place to begin your quest for “Olympic Gold”’.

Here's what's happening on HealthTap:

YOUR HEALTHSCORE:

 

WELLNESS SERIES- Let’s Get Grilling !

How do you Match Up  for the Gold ? Your Olympic athlete body match

Imagine the rush of an Olympic sprint, high dive, or pole vault: now that's easier than ever with the BBC's "Your Olympic athlete body match" app. Find out if you are built like a Chinese gymnast, an American swimmer, or a Ukrainian lifter. Dream big and be inspired!

Find a Social Media Companion for Wellness

 

Technorati Tags: #hcsm,#health,#wellness,#social,#olympics,#london,#mhealth,#mapp

 

 

Health Train Express is Social Media, is Your Blog?

 

I spoke to soon. Health Train Express will be around for a long time.

The responses to my announcement surprised me. I had many more readers than I had realized.  I guess analytics don’t always work, or I used the wrong ones.

After the announcement I quickly realized that blogs will never be dead. They amount to the  21st century ‘Journal’ for daily thoughts (used to be called a diary).  Perhaps I should rename it  e-Diary

While I enjoy using Google Plus, Twiiter, Facebook, to gesticulate, propose, analyze or ridicule.

Health Train will remain an important piece in my social media project.

I admit it, I failed I could not give up my platform.  There are  too many issues to  write about and a blog is the best for me. 

Physicians must not allow their patient to remain passive and just accept what Government decides to offer them in health. 

Physicians empower your patients. Patients empower your physicians.

What changed my attitude?   Of course, it is Regina Holladay

          

Here is a larger version of The Walking Gallery…deserves a better view.

 

There you have it.  Regina Holladay has been at this for several year . All of the stories are a visual treat and a testimony to patients.  Regina expresses her pain and frustration let hospital systems while her husband suffered with cancer.  Something we all know about and share our concerns with her.  Thank you Regina Holladay

WILL YOU TAKE THE RED PILL, OR THE BLUE PILL ?

MedStarter is an outgrowth of a social network innovation, KickStarter. Kickstarter is another social media approach to funding startups that require small amounts of capital as an investment through donations for worthwhile ideas.

 

Technorati Tags: medstarter,kickstarter,regina holladay,hcsm,patient advocacy,health train express,cancer,walking gallery

End of An Era

 

As I have read somewhere, ‘Nothing lasts forever’.

And so too are the lights going off here at Health Train Express.

It has been an eight year run with close to 1000 posts.

This will be the last Health Train Express blogpost.  A big thank you to ‘Blogger’ as well, now owned by Google.

In keeping with the trend Digital Health Space will assume the role of The Health Train Express

Health Care is undergoing some radical and important changes, and deservedly so in the 21st Century,  Now that we have survived Y2K (I think that is a pretty safe bet) I have evaluated the blog and what is happening in social media as well.

During the past six months our analytics reveal that my opinions and comments receive a much more global audience using social media, and further analysis also revealed that Google Plus will become my exclusive platform for the forseeable future. Of course nothing on the internet can be set in stone. Social media in medicine and health care has become well established. While Twitter and Facebook offer platforms, the unity of Google, Google Docs, Gmail, YouTube, Google Plus and Video Conferencing will allow me to video broadcast and interview important social media personalities using an integrated platform.

See you on the ‘other side’.

Gary Levin MD

This will allow the use of a central publishing source and eliminate much repetitive work.

Look for my comments, opinions, and diatribes on Google Plus at  +Digital Health Space.  Better yet put +Digital Health Space in one of your favorite circles.

 

Technorati Tags: youTube,google,facebook,twitter,google plus,hangouts,social media,gmail,healthtrain express,blogs,digital health space

The Costly Consequence of Health Care Reform

 

The Costly Consequences of Health Care Reform (Courtesy of the Budget Committee)

Paul Ryan, Chairman, Committee on the Budget, U.S. House of Representatives

 

Let’s carry that a little bit more, forward, “If you earned a medical degree, or PhD, thank the government.  I remember borrowing and working my way through college and medical school.  The government did not give me loans, the banks did and the government ‘backed them’ since students did not have income or usual credit standing.  For a man who went to Harvard, Obama does not seem to understand very much. Who paid for his education?  Did he make it on his own, does he thank the government for what he has….the best insurance in the nation, a 747 to fly on, limousines, secret service, free room and board.  Barry, give us a break ! You are a liar and a hypocrite.  I don’t expect you to tell us that you lie, liars never do and liars never even know they lie !

Posted April 8, 2010

“I can make a firm pledge.  Under my plan, no family making less than $250,000 a year will see any form of tax increase.  Not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes,”
President Obama, September 12, 2008

Beginning January 1, 2013, Obama Care imposes a 3.8% Medicare tax on unearned income of “high-income” taxpayers which could apply to proceeds from the sale of single family homes, townhouses, co-ops, condominiums, and even rental income, depending on your individual circumstances and any capital gains tax exclusions. Importantly, the “high income” thresholds are not indexed for inflation so will reach increasing numbers of middle-class taxpayers over time.

In February 2010, 5.02 million homes were sold, according to the National Association of Realtors (NAR). On any given day, the sale of a house, townhome, condominium, co-op, or income from a rental property could slam middle-income families with a new tax they can’t afford.

The new Obama Care tax is the first time the government will apply a 3.8 percent tax on unearned income. This new tax on home sales and unearned income and other Medicare taxes raise taxes more than $210 billion to pay for Obama Care.

The Costly Consequences of Health Care Reform (A legislative Review)

The issues are bi-partisan, Responsibility lies both at the feet of Republicans and Democrats.  Neither side can plead innocence.

 

Technorati Tags: Paul Ryan,Obamacare,healthcare social media,congressional budget

PPACA is Coming Soon To Your Neighborhood

 

“No matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period.”

President Barack Obama,
Speech to the American Medical Association
Chicago, June 15, 2009

In truth, prospects are bleak that you will be able to keep your doctor and even bleaker that there will be enough doctors to meet demand under Obamacare.

Patients and physicians are about to be hit smack in the face by the increased demand for healthcare services that will occur as PPACA becomes effective.  Physicians will no longer to be able to bear the brunt of reductions or new methodology of physician reimbursement.

Studies show that the rate of early physician retirement, or a move to another professional career,  are and will be occurring over the next 15 years. There is also  no way to predict what the effect of PPACA will have on older practicing physicians. Many will chose to leave without their retirement portfolio fully funded.  Rather than risk future losses from their medical business with increased overhead, the burden of IT, malpractice risks, and increased patient volume….many will leave medicine and seek other opportunity.

An Investor’s Business Daily/TIPP survey conducted in September of 2009 found that 45 percent of doctors said they “would consider leaving their practice or taking an early retirement” if the health law stands.

More than 800,000 doctors were practicing in 2006, according to government data. Projecting the poll’s finding onto that population means that 360,000 doctors would consider quitting!

And even without a mass exodus, the Association of American Medical Colleges envisions a shortage of about 160,000 doctors by 2025.

The greatest tragedy of Obamacare may be losing prematurely a generation of the most highly-trained, skilled physicians in history to a health overhaul law that the American people did everything they could to stop.

Physicians say they simply won’t practice under Obamacare rules that strip away much of their autonomy, drown them in bureaucracy, and leave them even more exposed to lawsuits.

Doctors are quietly making their plans now to restructure their practices, retire early, get another job, or otherwise protect themselves from the coming regulatory avalanche and payment cuts. 

ref:  National Review Online 

Another significant change has been the lack of trust in the AMA as witnessed by their flip flop during the debate on PPACA.  At first the AMA was in favor of the measure and then at the last moment was opposed to it as they measure the grassroots reaction to  PPACA.  With 850,000 physicians, only about 150,00 physicians belong to the AMA. 

By their own admission “AMA estimates that 60 percent of membership dues are allocable to lobbying activities of the AMA, and therefore are not deductible for income tax purposes. i.e., they are lobbyists. The question is who are they lobbying for? Physicians, patients, or themselves? Their self-interest is in survival, selling books, marketing insurance products, publishing a journal, and other activities.

The AMA has  radically reduced it’s membership dues to attract new members. Many of the members are students, or resident physicians in training, who received a special rate for membership.

I am an ardent supporter of health care reform, but can’t support PPACA (Obamacare) in it’s present form.  Some are now pronouncing how much easier it would be “just to continue on the present path.

What do you think?

The Olympic Flame Out for the N.H.S.

 

Feeling the Heat ?

   

During the past year or I have been reading about the change being made to the NHS, and the privatization as well as de-constructing it’s bureaucracy to allow more local control and administration..

So what was this opening ceremony about how wonderful the NHS is?  Certainly it did honor the thousands of health care professionals,nurses, and physicians who work in the setting of the NHS.  It also shamefully ignored the international theme of past Olympics and inappropriate for the setting, although it was masterfully done.  I don’t want my humble opinion overshadowing the event itself.   The two most  notable events were James Bond and Queen Elizabeth sky diving to the opening ceremony.  Mr. Bean also added a symphonic note to the ceremonies.  No one can fault the Brits for their ‘dry humor’.  It eclipsed  G.W.H. Bush and his sky-diving antics for several  birthdays.

This may have been staged to honor the NHS workers, but it came across as a politically inspired, and government funded advertisement, for who? Was this a message to the United States for Donald Berwick’s acclaim for socialized medicine?

They have had this system for decades, it’s taken that long to analyze it’s worth, and that long to make a change.  It’s going to take some time to analyze the internal workings of NHS to find out how they use outcome studies, assess quality of care and other metrics. (do they have meaningful use for their electronic health record system?)

  Marilyn Tavenner, MHA, BSN, RN.

Does our current ‘acting head of CMS participate in social media to effect openness and transparency (a ‘buzzword’) for President Obama.  It would be far more effective and efficient to use social media rather than the hierarchy of titles, distant meetings by health consultants and the multiplicity of meetings, mostly held in the Washington, D.C. area at one end of our large country. 

Most physicians can ill afford the time lost to go to a distant meeting, that does not offer CME.  There is no reason whatsoever that HHS cannot schedule meaningful webinars and links to information about the processes.

Technorati Tags: cms shared savings,transparency,cme,nhs,olympics

Digital Health Space

 

      

We have been working on a new entity for about 12 months on Google Plus. Digital Health Space.

Google plus is now a key feature for Google, which is tightly integrated with Gmail, Search, Google Docs,  and many other  features for Google.  Google has become much more than a search engine.  Vic Gundrota, Vice-President responsible for the new Google Plus and Google Hangouts likes to call Google a ‘destination site'”.

Google purchased YouTube a little more than a year ago, and has now tightly integrated it into their overall selection of application.  Many healthcare providers have produced videos of surgeries, educational materials and much more, hosted on YouTube,, and easily accessible from their social media stream on Google Plus.

Google Gmail has added a hangout feature on their email site. It is possible to open a hangout directly from Gmail.   It is also  possible to build several different business pages on Google Plus.  Among our pages are +Digital Health Space, +Health Care Social Media, + G+MD .

Digital Health Space is also developing a weekly Hangout on Air for health professionals.  Watch for further announcements here, on Google + and twitter as well as Facebook.

Technorati Tags: digital health space,G+MD,healthcare social media,sliderocket,Google plus,Google hangout,YouTube,Gmail,Google search,Vic Gundotra

Dr. Tom Ferguson, e-health Pioneer, Has Died

 

In April 2004 an important persona in health care social media passed on. I thought it a timely subject for a Sunday morning.

John M. Grohol, PsyD  Chief Editor and founder of PsychCentral  writes about Tom from a personal perspective, as opposed to those of us who read him via his internet blog and other activities.

 

This face is familiar to early bloggers in the health field. Tom is an original visionary in what the internet meant to everyone in healthcare and all the other places we see on the world wide web.

He originated in the early 1990s around the time that web browsers came into being. Prior to that posting or reading on the world wide web was done with archaic commands (http)  (ftp) which are now integrated seemlessly into web browsers.

Back in the early 1990′s we were both thinking about how the Internet was changing the roles of doctor and patient.

Thriving online self-help support communities available (yes, this was before the Web became popular) where tens of thousands of people went online everyday and offered self-help support and care to one another.

Was this the seeding of what we now know as social media in medicine?

He thought it was amazing people were already harnessing the power of online technology connections to bring it to online human connections where the technology simply faded into the background. He was the first doctor I knew who ever spoke so plainly about the future of healthcare, where he envisioned empowered patients taking care far more into their own hands, and doctors acting more as professional guides to help along the way.

He authored a series of white papers about the new revolution in health, but which morphed into a book by the time they were completed. The white papers were entitled, “e-Patients: How They Can Help Us Heal Healthcare,” the white papers turned into a book that will eventually be published with ideas on how ordinary people can help fix healthcare in America.

He and others talked about the new breed of “e-patients,” and where ideas percolated such as each person having their own health “dashboard” would be invaluable to an individual living healthier, better lives. The vision was limitless.

He was one of the pioneers in e-health, but unfortunately most of his thinking was just too far ahead of what a business could actually market or sustain. Despite that his seed took root and eventually has bloomed. 

 

Besides, how can you build a business around an empowered consumer patient, when all of the power in the healthcare system in America was in the hands of the all-knowing doctors and the insurance companies? But that never stopped him from trying.

Today our patients are more empowered with social media, advocacy groups and the idea of “patient centric medicine”.

Finally, perhaps if physicians and others had come together with a unified face the outcome of health care for all would not be so adversarial.

After all, the physician and the patient have the same goal….good health.

In the 1990s as the business model for medicine was  beginning to change, only a few adapted, the majority were left behind.

Have We Been Here Before?

 

This blog has been prepared by the author, Gary M. Levin MD as a preparatory narrative for forming an ACO and/or Medicare Shared Savings Group.

This information is reprinted from the regulations promulgated by:

Not for the faint of heart.

Accountable Care Organizations, Guidelines for Medicare Shared Savings Programs

Today we start a …multi-part narrative on how ACOs are formed, the process and explanations of numerous templates to legally form an accountable care organization.

It's a brave new world. Some of the issues sound very much like the failed health maintenance organizations of the 1990s, although the process is much more defined and carefully regulated by CMS. The agreements solely pertain to Medicare and eligible Medi-caid participants. Nothing is said about private insurers or the remaining marketplace.

It may be assumed that CMS leads the way in a controlled marketplace, while the private market will operate under the free market system with price competition and guidelines taken from CMS in regard to outcomes and quality of care.

It is a giant leap of faith that this will work across the country. The expense of establishment of ACOs is not known. Most of the early ACOs are already well organized health systems which serve as the foundation for layering an ACO upon it. In markets that do not yet have ACOs the burden is upon the local stakeholders to begin the process. An unknown factor for these less privileged hospitals and providers is the cost of organizing and the overhead and cost factors to determine what their rates will be. It will not be a cookie-cutter process.

Chances are very likely that insurance companies will evaluate and dictate their payment structure taking into account the federal regulations that not more than 15% can be allocated to their own administrative costs. Hospitals and ACO providers will have to negotiate from a position of relative weakness given the market power of CMS and larger and larger health insurance companies. Wellpoint's acquisition of another company (Amerigroup) for $4.9 billion dollars bespeaks the profits insurance companies sit upon. It begs the question why health care is so expensive in the first place.

As usual CMS has a project deadline that is heavily loaded upfront requiring entities to organize and file applications on relatively short notice (much like HIT incentives and meaningful use) with enrolled providers signed into the ACO. Most of this on faith that it will work financially. In other words, sign on the dotted line, and then we will tell you how you and how much you will be paid.

Requirements:

An ACO participant is identified at the billing TIN level. An ACO provider/supplier is a practitioner billing through the ACO participant’s TIN.

We want to ensure that each applicant understands the definition of an ACO participant and ACO provider/supplier. According to the regulations at 42 CFR 425.20, an ACO participant means an individual or a group of ACO providers/suppliers that is identified by a Medicare enrolled TIN that alone or together with one or more other ACO participants comprises the ACO. For example, an ACO participant may be a solo practice, a group practice, a hospital, an FQHC, among others.

An ACO participant may be composed of one or many ACO providers/suppliers that use, or have reassigned their billings to, the ACO participant TIN. An ACO provider/supplier means a provider or supplier enrolled in Medicare that bills for items and services furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant. The key point is that an ACO participant is identified by its Medicare-enrolled TIN.

All ACO providers/suppliers billing through an ACO participant TIN are included in the ACO by virtue of their relationship to the ACO participant and the ACO participant’s relationship with the ACO.

The Medicare Shared Savings Program is a program designed for ACO participants, as described above, that come together to form an ACO. Many important program operations use claims and Center for Medicare Medicare Shared Savings Program

Page 2 of 4

other information submitted to CMS by the ACO participant through its billing TIN, including calculation of shared savings, assignment, and benchmarking. Therefore, an ACO cannot apply to participate in the Medicare Shared Savings Program unless the ACO participants have agreed to participate in the Medicare Shared Savings Program and to comply with the program regulations.

The ACO applicant also must ensure that all ACO providers/suppliers associated with each ACO participant TIN have agreed and will comply with the program regulations.

Consequently, an ACO may not include an entity as an ACO participant unless all providers and suppliers billing under that entity’s billing TIN have agreed to participate.

Agreements or contracts between or among the ACO, ACO participant, and ACO providers/suppliers related to participation in the Medicare Shared Savings Program must be executed before the ACO submits its application.

As part of the application process, we ask that you submit the list of ACO participants, who, along with all the ACO participants’ associated ACO providers/suppliers, have agreed to participate in the program. This means that the ACO participants you submitted or will submit, in addition to all their associated ACO providers/suppliers, signed agreements or contracts before the application was or is submitted.

It is important that agreements between and among the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities comply with our regulations.

Content of agreements or contracts between the ACO and ACO participant.

As part of the application process, we ask that you submit a sample agreement you have with each of your ACO participants. This sample agreement and the associated executed agreements with ACO participants, at minimum, MUST contain the following:

1) An explicit requirement that the ACO participant agrees to participate in and comply with the requirements of the Medicare Shared Savings Program under 42 CFR part 425.

General references to compliance with Federal law are not sufficient. General references to compliance with Medicare regulations are not sufficient.

2) A description of the ACO participants’ rights and obligations in, and representation by, the ACO, including how the opportunity to share in savings or other financial arrangements will encourage ACO participants and ACO providers/suppliers to adhere to the quality assurance and improvement program and evidence-based clinical guidelines and should include language giving the ACO the authority to terminate an ACO participant for its non-compliance with the ACO’s participation agreement with us or any of the requirements of 42 CFR part 425.

Additionally, ACOs must not require that beneficiaries be referred to ACO participants or ACO providers/suppliers or to any other provider or supplier (42 CFR 425.304(c)(2)), except under the specific and limited circumstances expressly permitted by the regulations.Medicare Shared Savings Program

Page 3 of 4

The ACO may or may not need a separate legal entity, however the ACO governing body must have a specific fiduciary duty to the ACO.

“””We want to ensure each applicant understands the eligibility requirement related to the ACO’s governing body. According to the regulations at 42 CFR 425.106, the ACO must maintain an identifiable governing body with authority to execute the functions of the ACO.

The governing body must have responsibility for oversight and strategic direction, holding the ACO management accountable for the ACO’s activities. The governing body members must have a fiduciary duty to the ACO and must act consistent with that fiduciary duty.

• The governing body of the ACO must be separate and unique to the ACO in cases where the ACO comprises multiple, otherwise independent ACO participants.

The governing body members cannot meet this fiduciary duty requirement if the governing body is also responsible for governing the activities of individuals or entities that are not part of the ACO.

• If an already existing entity applies to the program as an ACO, the ACO governing body may be the same as the governing body of that existing entity, provided it satisfies the other requirements for a governing body, including the fiduciary duty requirement.

These regulations mean that if your ACO is comprised of two or more otherwise independent ACO participants, your ACO must have a legal entity and governing body that is distinct and separate from each of them (the governing body must be the governing body of the legal entity that is the ACO, and not the governing body of a parent or subsidiary entity).

For example, if several separate group practices decide to come together for purposes of participating in the Medicare Shared Savings Program (but will otherwise maintain separate practices), they must form a separate legal entity to be the ACO.

This legal entity must have a legal structure with a governing body that has a fiduciary responsibility to the ACO alone and not to any other individual or entity. If an existing entity, such as an IPA representing many group practices wants to apply as an ACO using its existing legal structure and governing body, each group practice represented by the IPA must agree to be an ACO participant and each provider and supplier within each group practice must agree to be ACO providers/suppliers as discussed above.

If only some of the represented group practices want to become ACO participants, the IPA cannot use its existing legal structure and governing body for the ACO, because it cannot meet the regulatory requirements, including the fiduciary duty requirement.

If only some of a group practice’s providers and suppliers agree to be ACO providers and suppliers, then that group practice may not become an ACO participant.

In summary, the ACO’s governing body decisions must be independent from influence of interests that may conflict with the ACO’s interests, including the interests of group practices that are not participating in the ACO but continue to be represented by the IPA for other purposes, such as commercial contracting.

Assess your application for the Medicare Shared Savings Program.

Please review this memo carefully and consider your current ACO organization, agreements, and application attestations in light of it. “””

List of Required Documents for ACO formation and Application to become an ACO for CMS approval process.

Medicare Shared Savings Program

Submit FormCMS-20037 Application for Access to CMS Computer Systems no later than July, 9 2012

See How to complete Form CMS-20037 [PDF, 427KB] for instructions on how to complete your CMS 20037.

Your application is pre-populated with the information you gave us on your Notice of Intent to apply (NOI).  If you find an error in any pre-populated information, send an email with the change request and correct information to SSPACO_Applications@cms.hhs.gov.  In the subject line, include your ACO ID and the words “Request to Change Pre-populated Information.”

How to Submit an Application if you are a Physician Group Practice Transition Demonstration Participant

This group has special privileges in regard to abbreviated applications.

How to Complete the Application

Use the MSSP Reference Table [PDF, 506KB as a guide as you complete your application in HPMS. See 2013 Medicare Shared Savings Program Application Form [PDF, 259KB] for a copy of the application questions. Be sure to use the required templates,

All the documents you submit must clearly identify you as the ACO applicant with the identification number (ACO ID) you got with your Notice of Intent to Apply (NOI) acknowledgement e-mail

Some questions require you to submit supporting documentation to us.  Using file compression software such as WinZip, compress each section’s files together.  Upload the compressed files in HPMS in their respective file upload locations.  Narratives and/or other supporting documentation are compressed and uploaded to the ‘Supporting Applications Materials’ location. This does not apply to your ACO Participant List. Use the ACO Module User Guide in HPMS for help uploading.

How to complete the ACO Participant List Template

Use the ACO Participant List Template [ZIP, 5KB] to give us your ACO Participant List. See How to complete Participant List Template [PDF, 424KB] for instructions on how to complete it. See also ACO Participant List Frequently Asked Questions.

How to Complete the Governing Body Template

Use the Governing Body Template [ZIP, 10KB] to tell us about your Governing Body. All fields relate to the members on the Governing Body. Do not leave any fields blank.

See How to complete Governing Body Template PDF, 255KB] for instructions on how to complete it. See also Governing Body Frequently Asked Questions.

How to Complete the ACO Participation Agreement Template

Use the ACO Participation Agreement Template [ZIP, 282KB] to tell us about your agreements with your ACO participants. For additional guidance, see Additional Guidance for Medicare Shared Savings Program Accountable Care Organization (ACO) Applications [PDF, 113KB]

See How to complete Participation Agreement Template [PDF, 249KB] for instructions on how to complete it.

How to Complete the Executed Agreements Template

Read the guidance we issued around applicants, participants and agreements.

Use the Executed Agreement Template [ZIP, 11KB] to list the ACO Participants you have executed ACO Participation agreements with.

See How to complete Executed Agreements Template [PDF, 176KB] for instructions on how to complete it.

Requests for Additional Information

In two words: “ON DEMAND”

footnote:

We must get the requested information by the date specified on the CMS notice.  We consider the date of submission as the actual date we get the information, and not the postmarked date on the submission.

Patients and Providers: “We're from the Government and we're here to help you “

Applications posted on CMS Web site

Updated in July 2012

NOIs accepted  Nov. 1, 2011 - June 29, 2012

CMS User ID forms accepted Nov. 9, 2011 - July 9, 2012

Applications accepted

Aug. 1,2012 - Sept. 6, 2012 Application approval or denial decision

Fall 2012

Reconsideration review deadline* Dec. 11, 2012

Helpful Links and Additional Information

Final Rule Published in the Federal Register on November 2, 2011

Shared Savings Program Web site

Shared Savings Program Final Waiver

Statutes/Regulations/Guidance

Shared Savings Program Frequently Asked Questions

References:

Disclosures and Waivers:

None of the above information should be considered official and this document is NOT endorsed by CMS. The reader should not base decisions or deadline dates without first contacting CMS at the indicated email addresses listed herein.

 

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