AFFILIATED PHYSICIANS MEDICAL GROUP ACO, INC.
C/O MSO, INC. OF SOUTHERN CALIFORNIA
2295-A Huntington Drive,
San Marino, CA 91108
(626) 656-2370, Extension 101
ACO Primary Contact
Jonathan Nguyen, MD
Composition of ACO:
Physician-led Medical Corporation with representation from ACO Participants and Medicare beneficiaries
Affiliated Physicians Medical Group (APMG) was formed in 2008. Since inception, APMG has expanded its provider network into four counties: Los Angeles, Orange, San Bernardino and Riverside. APMG is currently coordinating almost 2,000 Medicare Advantage Members assigned through various health plans and has gained progressive experience in the cost effective and efficient care of Medicare recipients. APMG is aware that the Medicare Fee-for-Service beneficiaries will remain fee-for-service under the Medicare Share Savings Program and will have freedom to choose to see any Medicare-certified providers without prior authorizations. APMG believes, however that many of the principles of coordinated care (for example case management) would greatly enhance the quality and continuity of care provided to these Medicare Fee-for-Service beneficiaries.
The APMG participants have always been committed to providing quality care and services, primarily to the Cambodian, Vietnamese, Filipino and Hispanic communities in its service areas. APMG’s mission is to continue providing efficient and cost effective quality health care services in a cultural and linguistic appropriate manner to the Medicare recipients in its service areas. APCMG will use many of the managed care principles to promote accountability for its assigned population of Medicare Fee-for-Service beneficiaries, improve the coordination of fee for services items and services, encourage investment in infrastructure and redesign care processes for high quality and efficient service delivery, and incentivize high value care.
APMG is committed to having a care coordination plan tailored to each of the assigned Medicare recipient, taking into consideration the current medical and psycho-social profile of each recipient. The ACO will encourage preventive care, direct recipients/Medicare Fee-for-Service patients to the most appropriate and cost effective care settings and constantly monitor the health status of each recipient/Medicare Fee-for-Service patient to ensure optimal outcome.
APMG is affiliated with all of the primary hospitals in local service areas and is contracted with the majority of the specialists and ancillary providers who have provided health care services to the local communities for many years.
After the phone conference with representatives of CMS (Neal Logue and Dr. Terri Postma) on October 3, 2012, Affiliated Physicians Medical Group (A1696) decided to form a new Corporation. The name AFFILIATED PHYSICIANS MEDICAL GROUP ACO was reserved on October 4, 2012.
Fortunately, the name “Affiliated Physicians Medical Group ACO” was used in all the Letter of Agreements executed between the participants with A1696 and submitted to CMS as part of the initial Medicare Shared Savings Plan. The Letter of Agreement also have all the required languages for the Medicare Shared Savings Program, specially the provision that Medicare Fee-for-Service beneficiaries retain the freedom of choice to see any Medicare approved providers without any requirements for prior authorizations.
The Statement of Incorporation for AFFILIATED PHYSICIANS MEDICAL GROUP ACO was mailed to the CA Secretary of State on October 4, 2012. We requested that the Corporation obtain approval as soon as possible so we can proceed with application of a Tax ID and NPI numbers. AFFILIATEDPHYSICIANS MEDICAL GROUP ACO will notify CMS once the Corporation and Tax ID numbers have been approved and will immediately open a bank account and complete and submit CMS Form CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement
With the new Corporation, AFFILIATED PHYSICIANS MEDICAL GROUP ACO will definitely meet the CMS requirement defined in the Medicare Shared Savings Program regulations at 42 CFR Part 425, specifically that the ACO provide for meaningful participation in the composition and control of the ACO’s governing body for ACO participants or their designated representatives. Four ACO participants and one Medicare Beneficiary Representative have been appointed to the AFFILIATED PHYSICIANS MEDICAL GROUP ACO Governing Body, also meeting CMS’s requirement that ACO participants have at least 75% control of the ACO’s governing body.
|Member Last Name||Member First Name||Member Title/Position|
|Nguyen||Tuan Xuan||Medical Director|
|Saylor||Teresita||Member of the Governing Board|
|Nguyen||Cong||Beneficiary Member of the Governing Board|
The ACO will be responsible for identifying any variance from the standard of care, either as a sentinel event if an unjustifiable adverse outcome warrants immediate action or based upon a pattern of practice which falls out of the established program and community standards over a period of time. Utilization patterns may be identified by historic claims data retrospective utilization review. When utilization, quality assurance or quality of care concerns are identified, a corrective action plan is required to be established by the ACO Governing body or its structured committees which may include but is not limited to provider/participant education, staff development, administrative changes, provider/participant contract changes and alteration of provider/participant privileges.
The ACO Governing body shall follow the successive guidelines in the event a Provider/participant or provider/participant/supplier does not comply with utilization coordination patterns or quality coordination as set by the ACO Governing body:
- Education and/or re-orientation to the policies and procedures of the ACO physician network
- Counseling by a peer of the physician as to network’s goals, need for compliance with policies and procedures, ethics, etc., or counseling of a provider/participant/supplier
- Written warning of impending sanctions
- Retrospective review of all claims activity as provided by CMS
- Limitation placed on scope of practice, and/or requirement for continued education
- Suspension from participation with the ACO physician network until evidence of compliance is shown
- Termination of the ACO relationship or termination of contractual relationship with the provider/participant/supplier.
All provisions of service are provided in a beneficiary centered model. The beneficiary is encouraged to have ownership of their healthcare goals. Beneficiaries are valued for their contributions to their care and are respected as unique individuals. Families and support systems are always welcomed and included when available.
THE HEALTHCARE TEAM
The healthcare team will consist of, but not limited to: Physicians, Registered Nurses, Pharmacist, Social Workers, including a Licensed Therapist and office staff. The beneficiary is at the center of the team. A Palliative Care RN will be available to assist those with life threatening conditions. The Health Care Team is also a component of the Case Management Program.
CASE MANAGEMENT PROGRAM
One of the real services offered by the ACO is the presence of Case Management and the direct referral process for Case Management. This is a collaborative course of action, as the Case Manager will also notify the PCP and attending physicians of on-going case management. The co-ownership of Case Management between the physicians and ACO clinical staff will move the care plan items forward more efficiently and conveniently for the beneficiary.
The entire program focuses on key diseases and aims to reduce avoidable acute inpatient admissions and unnecessary emergency room utilization.
Providers/participants may make referral to Case Management.
Beneficiaries or family may make a self-referral to Case Management. Initial conversations may be focused on another issue, but the on-going dialogue may reveal multiple care issues.
Any beneficiary who is identified as requiring assistance in managing and acute or chronic health problem including, but not limited to, frequent hospital admissions or emergency room visits, non-compliance with medical management protocols, catastrophic illnesses or injuries or complicated/complex conditions are appropriate candidates for case management.
The ACO Case Management program consists of the following:
Identification and screening of beneficiaries who are experiencing difficulty or have potential for requiring assistance in managing their health care needs;
Assessments of the clinical, environmental, physical and psychosocial factors that influence the beneficiaries’ ability to comply with a treatment plan or participate in managing a healthy life style;
The beneficiaries will be engaged in shared decision making, with consideration to the beneficiaries’ individual unique needs, preferences, values and cultural alignment;
Development of a care plan that reflects the priority needs of the beneficiary and is coordinated with other providers/participants;
Identification and coordination of services that match the needs of the beneficiary with the available and appropriate resources;
Monitoring and reassessment of the care plan based upon the beneficiary’s’ progress towards achievement of established goals;
Maintenance of confidentiality and organization of the beneficiary’s’ case management file
ACCESS TO COMMUNITY RESOURCES
This is to incorporate access to community resources into the care planning of beneficiaries and ensure information about community resources is provided to beneficiaries.
Community Resource Programs provide services such as transportation, meals-on-wheels, nutrition programs, counseling, friendly visitor, telephone re-assurance, legal counseling, etc.
All Case Management staff shall be oriented and have ready access to community resources that can supplement or complement the care programs beneficiaries.
Beneficiaries shall be referred to community resources, if needed, in their area of residence in order to enhance the coordination of services and to ensure continuity of care.
The need or desirability for community resources may be identified in a variety of ways:
During the analysis of the initial health risk survey provided to all beneficiaries;
During beneficiaries’ visit to the PCP or Specialist;
During an inpatient stay and/or preparation for discharge (Discharge Planning);
At the time of an emergency visit;
When a beneficiary accesses services outside the network;
At any time during acute or chronic care management; and,
As a result of communication with the provider/participant (PCP or specialist or both), family member or authorized representative
The role of Case Management staff will include at least the following:
Submitting referrals to the appropriate community resource;
Discussing the value and potential benefit of community resources with the beneficiary and family, when appropriate;
Assisting with appointments and arranging transportation as needed; and,
Community and educational based resources
The importance of incorporating community resources in caring for beneficiaries is communicated to network providers/participants/participants, especially PCPs. This is accomplished by providing access to community resources in the provider manual, periodic reminders via newsletters/emails and face-to-face meetings.
Compliance with this requirement will be incorporated into the onsite review visits and medical record reviews.
ACUTE CASE MANAGEMENT
Beneficiaries admitted to acute inpatient or secondary facilities will be overseen by the ACO Case Manager in collaboration with the facility based Case Manager. ACO Case Manager may make on site visits to the beneficiary and for the purpose of record review. Anticipatory post discharge needs will be planned. Medication reconciliation will be captured at discharge and forwarded to the Case Manager.
DISCHARGE PLANNING AND POST DISCHARGE CASE MANAGEMENT
The Case Management staff will evaluate the acute stay discharge requirements of all beneficiaries and provide telephonic follow up on any beneficiary at risk.
The Case Management staff will contact beneficiaries post hospital discharge to determine if there are care issues or access problems.
The goal of a discharge telephonic interview is to assure that the beneficiary is and will be receiving the care recommended at the time of discharge; prevent readmissions to the hospital, and early identification of new care requirements.
Of special concern are the following areas that would have been addressed in the beneficiaries’ discharge plan:
Do beneficiaries have their medications?
Did they schedule an appointment to follow up with the attending physician or surgeon?
Do patients have transportation to their appointments?
Are they getting adequate nutrition and fluids?
Are they able to ambulate? Has there been any fall or any other indication of an unsafe environment?
Is a caregiver present or needed?
Was home health or other DME ordered and delivered?
Are there ongoing wound care or other physical care needs?
If during the telephonic interview, the staff member identifies a care issue or social problem, a timely plan and intervention is made. Interventions would include:
A call to the provider/participant or attending physician to acquaint them with the issues and solicit assistance with the care plan;
Follow up with the Home Health agency or DME provider on ordered services, as appropriate;
Calls to the Case Management Department at the discharging facility;
Requests for health education materials;
Intervention by local, regional, or state agencies if there is suspected abuse
Identification of social service resources within the community that may meet needs;
Referral of the beneficiaries’ case to Governing Board if a quality of care issue is suspected
The ACO will use nationally developed and accepted written review criteria updated to the most current version available, i.e. Milliman Care Guidelines 12th Edition, Apollo Consultants, InterQual, guidelines in the CMS website for National Coverage Decisions (NCD), General Medicare coverage guidelines, and the local Medicare contractors written coverage decisions, (LCD) [which have to be used as first criteria and guidelines for Medicare members], The American College of Obstetrics and Gynecology, The United States Preventative Services Task Force Standards and other guidelines approved and disseminated to the ACO. Locally used criteria sets include specifications of Title 22 of the California Code of Regulations, the Los Angeles County Department of Health and Human Services Health Care Guidelines and Requirements, and the AHRQ National Clearinghouse at http://www.guideline.gov/. Review criteria are updated on an ongoing basis. For nationally recognized criteria sets they will be renewed at least every two years. Additionally, the ACO governing body recognizes that individual needs and or circumstances may require flexibility in the application of the ACO’s delivery system. Age, illness and co-morbidities, complications, home environment, individual progress and psychosocial needs are all considered in the evaluation of the beneficiary. Providers/participants contracted with the ACO are informed of guidelines used by the ACO through provider newsletters and memorandums or other communications. In addition, clinical criteria may be sent by fax, mail, or read to the physician over the phone. These provider/participants are welcomed to participate in the development of clinical guidelines and review criteria.
Consistency of application of criteria is monitored through retrospective analysis of claims data provided by CMS.
The Medical Coordination team informs providers/participants and vendors of all treatment guidelines and policies. The guidelines shall be disclosed by the ACO to provider/participants and beneficiaries upon request, and to the public upon request.
PREVENTATIVE HEALTH CARE SERVICES-CLINICAL GUIDELINES
The ACO will distribute Preventive Health Guidelines to providers/participants annually. Review of the preventative health care measures is a component of the ACO governing body or any appointed committees. Annually, the CDC Preventive Guidelines are reviewed and approved by the ACO governing body or appointed committees.
The ACO follows guidelines mandated by the State Department of Health Services (SDHS). Guidelines may include, but are not limited to those of the U.S. Preventive Services Task Force, the Centers for Medicare and Medicaid Services and national guidelines distributed through the AHQR.
The U.S. Preventive Services Task Force (USPSTF) was convened by the Public Health Service to rigorously evaluate clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications.
Preventive Health Guidelines are distributed through a variety of methods:
- Provider newsletters
- Provider orientation materials
- Special mailings
- Provider inquiry
Use of Preventive Health Guidelines is promoted throughout the year through a variety of channels to increase both awareness of the guidelines and beneficiary utilization of preventive health services.
The ACO shall cover and ensure that contracted primary care provider/participants provide of all medically necessary diagnostic, treatment, and follow-up services, which are necessary given the finding or risk factors identified in initial health assessments or during visits for routine, urgent, or emergent health care situations. The ACO shall ensure that these services are initiated as soon as possible but no later than 30 calendar days following discovery of a problem requiring follow up.
The AHRQ website contains not only the Preventive Health Guidelines but also recommended treatment guidelines. These guidelines may be more up to date than the state guidelines. http://www.ahrq.gov/clinic/cps3dix.htm.
The ACO will attempt to create a “Circle of Care” for all beneficiaries. This Circle of care is comprised of all vital participants involved in the beneficiaries care. (See diagram below). The ACO realizes that the Circle of Care cannot be mandated but rather must be presented to the beneficiary as an intended partnership;
The ethnical and cultural diversity of the beneficiary will at all times be considered in assisting the beneficiary with care options and choices;
The beneficiary will be encouraged at all times to verbalize their perceived needs;
The ACO will utilize letters approved by CMS to encourage beneficiaries to engage and encourage having initial visit with the primary care providers that have seen most frequently in the past three years to have a complete Physical Exam/Total Health Assessment within 30 days from the time the Primary Care Physician with the plurality of primary care visits for each beneficiary has been identified;
The ACO will also encourage provider staff making outreach calls to the beneficiaries;
The ACO will involve family/caregivers/significant others, as allowed by the beneficiary, to encourage and assist the beneficiary in keeping appointments with an emphasis on the Physical Exam/Total Health Assessment;
The ACO participant may arrange in home assessment at beneficiary request;
The ACO will use claims or other data sharing provided by CMS to identify diagnostic codes (ICD9 or ICD10) and treatment or service codes (CPT) when member is treated outside the ACO circle of care.
For beneficiaries identified at risk or poor compliance, the provider refers beneficiary to Care Coordination for assessment and planning:
- The Care Coordinator assigned will contact the beneficiary/primary caregiver and begin the initial assessment of the member and Treatment Plan development;
- Each beneficiary has the right to either accept or decline Care Coordination services. The initial assessment will include the date, time, acceptance or refusal of case management and the name of the Care Coordinator;
- Involvement of other identified community stakeholders, i.e. clergy or religious/spiritual leaders, educators or others that have contact with the beneficiary;
- Beneficiary representation within the Governing Board;
- Beneficiaries will be contacted by the trained ACO interviewers who speak in the beneficiary’s dominant language;
CIRCLE OF CARE
B. Communication clinical knowledge/evidence based medicine to beneficiaries in a way that is understandable to them:
PCP participants will have the capability of speaking to the beneficiary/family/significant other/caregiver in the beneficiary’s primary or preferred language;
Evidence based medicine may be shown to the beneficiary in the form of clinical guidelines, i.e. Milliman, Apollo or other accepted guidelines. The guidelines may be printed out for the beneficiary, reviewed with the beneficiary, family, significant other or caretaker in the preferred language of same;
Beneficiary may be given brochures, handouts or other printed materials as appropriate;
Beneficiaries/family/significant other/caregiver will be given all opportunities to ask questions and alternatives to treatment explained in order for informed decision making to be done;
The beneficiaries will be engaged in shared decision making, with consideration to the beneficiaries’ individual unique needs, preferences, values and cultural alignment.
C. Engage beneficiaries in shared decision-making that takes into account the beneficiaries’ unique needs, preferences, values, and priorities;
As stated in A. above, the beneficiary/primary caregiver is invited to share in decision making as it is the beneficiary who is the identified center of care;
The beneficiary’s unique needs, values, priorities and cultural alignment will be respected by the care team.
All acceptance/decline of treatment suggestions, by the beneficiary/primary caregiver will be clearly documented in the medical record.
D. STANDARDS FOR BENEFICIARY ACCESS AND COMMUNICATION AND ACCESS TO MEDICAL RECORDS
Traditionally, Medicare beneficiaries or a person who has the designated power of attorney for the beneficiary access the beneficiary medical records by signing a Release of Medical Records information with each participant’s office.
The ACO will establish a toll free number for the beneficiary to call with any questions regarding the ACO, access to providers and community resources and will extend assistance to the beneficiary of the person with designated power of attorney to obtain medical records from any provider of services who have rendered care to the beneficiary.
ACCESS DURING OFFICE HOURS
To make beneficiaries access to the provider easier, the provider will:
- Afford same day appointment to all assigned beneficiaries;
- Providers will return phone calls during assigned hours and beneficiaries will have information regarding these hours.
ACCESS AFTER HOURS
Beneficiaries will have access to a 24/7 Call Line to assist the beneficiary with needs.
Beneficiaries will be given a list of Urgent Care Centers to be used in the event of an emergency
or as directed by the provider.
E. Use the internal assessments of these processes to improve continuously the ACO’s care practices.
The ACO Quality Management Committee will request Beneficiary Satisfaction Surveys to be completed by the beneficiary or his/her designated representative. This information will be collected, aggregated and analyzed on a quarterly basis. The feedback from the beneficiary/caregivers is critical in determining the value of the ACO from the beneficiary perspective.
Likewise it is also critical to have feedback from participant PCP and Care Team and/or Care Coordination as to the efficacy of the care approach and identify opportunities for improvement.
Data sharing from CMS will assist in determining the beneficiary’s actual utilization to identify situations where the beneficiary has moved outside the identified circle of care to receive services elsewhere. This will assist the team in understanding beneficiary preferences or if an opportunity to provide care was lost.
Standardized measures include, but may not be limited to:
Care for chronic health care conditions using standard guidelines such as implementation of ACE inhibitors, adherence to dietary programs, maintenance of blood sugar testing and insulin administration, or compliance with medication regimen
Evaluation of services against standard frequency of either normalized data such as Kaiser Family Foundation or CMS data to compare emergency department visits, or bed days per 1000
Review of ambulatory care sensitive admissions that could have been avoided with appropriate early intervention. The AHRQ book that contains these types of examples is the Window Into Primary and Preventive Care, 2000, HCUP Fact Book No.5, Agency for Healthcare Quality and Research found at www.ahrq.gov/data/hcup/factbk5/
Required ACO Quality Measurements:
The ACO must demonstrate meeting quality performance standards. CMS will measure quality of care using nationally recognized measures in the following key domains:
Patient /Caregiver experience, Care Coordination/patient safety and Preventive Health;
At risk population: Diabetes, hypertension, Ischemic Vascular disease, Heart Failure and Coronary Heart Disease.
The analysis of the measures will reveal the areas that will require intervention to improve performance. If the performance standard is not met, the Medical coordination team will collaborate with the provider in developing interventions and scheduling
re-measures to evaluate the intervention. Re-measures are important to trend the improvement and allow for additional or modification to the interventions. When the measurement goal is achieved and no further measures are required in either a patient experience measure or a clinical improvement area, then new areas of review will be selected based on other desired outcomes.
In performing the measurement analysis and testing the standard measurement, methodology to be implemented may include:
Standardized statistical methods: valid sampling, valid numerator and denominator, sample size confidence, and valid measurement periods
A stated performance goal based on clinical evidence or a goal in satisfaction measures
Comparison of the results of the measures and an analysis of any determined deficiencies in the intervention or process
Identification of opportunities for improvement which can change over time
Comparability of the data with consideration of different populations and time- periods even geographic and cultural differences
- The ACO is budgeting 60% of shared savings to reward the ACO Primary Care participants, 15% to other ACO providers and suppliers and will use 15% of the savings to reinvest in the ACO’s infrastructure and redesign processes of care and 10% to establish reserves for future investments, incentives and future participation in the next Contract Period when it will probably have to participate in Track 2 risk sharing which includes sharing in both savings or loss.
- The Shared Savings will be allocated as follows:
- For the ACO Primary Care Physicians: Thirty percent (30%) of the shared saving bonus toward reporting and improving on the 33 quality measures set by CMS. In Performance year 1 (2013), since CMS is only requiring ACOs to do complete and timely reporting of the quality measures, APCN-ACO will have the same expectation of primary care providers, specifically for 22 measures (since CMS will be collected and calculated by CMS). In Performance Year 1, only primary care physicians who submit complete and timely reporting of the required quality measures will receive a bonus. Starting Performance Years 2 and 3, the ACO will only award this bonus to those primary care providers who meet or exceed CMS’s benchmark for pay for performance bonus.
- Equal distribution of thirty (30%) shared savings bonus to each of the contracted primary care providers.
- Equal distribution of fifteen (15%) shared savings bonus to contracted specialists and ancillary providers.
- Fifteen percent (15%) of the shared savings bonus will be allocated to investing in data systems allow for tracking quality measures and giving feedback to providers. In addition, the ACO will assist contracted primary care providers to install or supplement their Electronic Health Records (EHRs) and encourage patients to communicate with their physicians over the Web or by e-mail, create a blended patient registry for all chronic conditions that identifies patients with multiple chronic conditions,
focus case management by diagnosis and high impact patients and integrate case management with planned visits and point-of-care information from disease registries.
- Performance Year 1: N/A (2013 is year 1)
- Performance Year 2: N/A (2014 is year 2)
- Performance Year 3: N/A (2015 is year 3)
- Reinvest in infrastructure: 15%
- Distribution to ACO Participants and reserves: 85%
- Primary Care Professionals: 60%
- Specialists: 15%
- Reserve: 10%
subsidiary Collaborative Health Solutions to form an Accountable Care
Organization (ACO). An ACO is a provider based organization authorized
by the Centers for Medicare and Medicaid Services (CMS) to provide care
for Medicare Fee-for-Service beneficiaries. To directly quote the CMS website, the
purposes of an ACO include: “…help doctors, hospitals and other health
care providers better coordinate care for Medicare patients.” “…create
incentives for health care providers to work together to treat an
individual patient across care settings.” “…reward ACO’s that lower
their growth in health care costs while meeting performance standards on
quality of care and putting patients first.” This is a very exciting
development for the physicians in Health First Network. It not only
places them in the forefront of health care reform, it gives the
physicians the ability to make their own determinations of how care is
to be coordinated and delivered to patients. Added to this is the fact
there is opportunity for the physician to earn a share of any savings
achieved with no downside risk.