Prospective Network Participants - OneCare Vermont

Prospective Network Participants

Vision and Description

Vision: The University of Vermont Medical Center and Dartmouth-Hitchcock, the leading academic medical centers serving the state of Vermont, have formed OneCare Vermont and built a network of providers that will coordinate to improve the quality of care while managing the cost of that care for Medicare beneficiaries. OneCare Vermont is a broad network of various types of healthcare providers and provider organizations from throughout the state forming an Accountable Care Organization (ACO) that will participate in the Medicare Shared Savings Program (MSSP) beginning January 1, 2013.

Description: OneCare Vermont will provide tools and support including software, training, data analysis, reporting, and clinical leadership to the network participants. In return, the network participants agree to share accountability for cost and quality performance across the participant network, to provide clinical data for attributed Medicare beneficiaries from their medical record systems, to participate in defined care coordination processes, and to assist in designing and implementing protocols and other interventions to improve outcomes for Medicare beneficiaries.

The Medicare Shared Savings Program

Overview of MSSP

The Medicare Shared Savings Program is a three year, renewable program that allows health care provider organizations (called “participants”) to earn a share of the savings achieved for a population of Medicare beneficiaries “attributed” to the participating providers (physicians or mid-level providers). Medicare attributes beneficiaries to ACOs based upon historical billing information of the ACOs network participants by identifying the predominant primary care relationship for each Medicare beneficiary. The total cost of care for all attributed Medicare beneficiaries across all network participants in an ACO forms the basis for measurement and potential for earning shared savings.

For OneCare Vermont network participants who are a primary care physician, a primary care provider group practice, or an organization which employs primary care physicians, your patients that are Medicare beneficiaries will likely be attributed to OneCare Vermont’s population of attributed Medicare beneficiaries. Although not as frequent, specialty physicians can also have Medicare beneficiaries from their practice attributed to OneCare Vermont. Organizations that do not have primary care providers may still be network participants, contribute to the coordinated care of attributed beneficiaries and be eligible for shared savings within the ACO.

The Medicare Shared Savings Model

OneCare Vermont network participants will continue to treat all Medicare beneficiaries and bill Medicare for services as they do today, and will be paid under their normal Medicare fee-for-service reimbursement models.  Medicare will establish an expected total cost of care target for OneCare Vermont based on all historical Part A and Part B expenditures for the attributed Medicare beneficiaries.  This target will include an increase factor for the national trend in Medicare expenditures.  If the actual total cost of care rendered to the OneCare Vermont-attributed Medicare beneficiaries is lower than the expected cost by more than the minimum savings threshold, the ACO earns shared savings from this difference.  Ninety percent of any shared savings received by OneCare Vermont will be distributed among the network participants. Ten percent will be used to partially offset expenses of OneCare Vermont.

Please note that OneCare Vermont has selected MSSP Track One with “upside only” potential.  This means you have no financial risk and will receive and keep the fee for service reimbursement you otherwise would for services performed and billed under the Medicare Fee-For-Service Program for the years 2013-2015. In “Track One”, upon meeting the minimum savings threshold and quality measures, OneCare Vermont can receive up to 50% of the savings achieved against the target, and neither OneCare Vermont nor its network participants pay any penalty whatsoever if we do not achieve our targeted performance.  This is known as “upside only” or “shared savings only”. In the alternative “Track Two” model, an ACO becomes financially liable (within limits) if Medicare Fee-For-Service costs exceed a threshold set by Medicare. This is known as “Downside Risk”. Under current rules, an ACO that initially selects “Track One” is required to assume a “Downside Risk” track if the ACO re-enrolls for a subsequent three year period, which for OneCare Vermont would be for 2016-2018. Neither OneCare Vermont nor its individual network participants are obligated to re-enroll in the MSSP or continue participation in the OneCare Vermont ACO beyond the initial three year period.

Quality Measurement and Performance Requirements

The MSSP has specified quality performance measures across four domains. OneCare Vermont will need to collect and submit data that will be used to generate an overall quality score for OneCare Vermont by Medicare. For year one of the MSSP, OneCare Vermont will only need to submit a complete data set to qualify for full savings eligibility (“pay-for-reporting”). In subsequent years, OneCare Vermont will need to meet a minimum performance threshold to be eligible for shared savings. 

If this minimum is exceeded and OneCare Vermont does achieve the cost target by more than the minimum savings rate, the actual shared savings amount will be adjusted by OneCare Vermont’s overall quality score. Medicare intends to publish these exact parameters as the “pay-for-performance” period (year 2) approaches.

Other Program Elements

Although there are additional required elements in the MSSP for an ACO organization, most of the program details are left to an individual ACO to define. This includes network development and participation agreements, shared savings distribution models, and clinical improvement approaches.