N.J. Admin. Code § 10:79A-1.6

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:79A-1.6 - Gainsharing plan submission and review

(a) The gainsharing plan shall set forth the ACOs comprehensive plans and processes for accomplishing the Medicaid ACO Demonstration Project objectives.The gainsharing plan shall outline the ACOs vision for improving health outcomes and the quality of care, as measured by objective benchmarks, as well as patient experience of care, for vulnerable populations by increasing access to primary and behavioral health care services and utilization of preventive care and reducing use of emergency rooms and in-patient care settings for routine care.

1. Criteria to be considered by the Department and the Department of Health in approving a gainsharing plan shall include, but are not limited to whether the gainsharing plan:

i. Promotes the following:

(1) Care coordination through multi-disciplinary teams, including care coordination of patients with chronic diseases and the elderly;

(2) Expansion of the medical home and chronic care models;

(3) Increased patient medication adherence and use of medication therapy management services;

(4) Use of health information technology and sharing of health information; and

(5) Use of open access scheduling in clinical and behavioral health care settings;

ii. Encourages services, such as patient or family health education and health promotion, home-based services, telephonic communication, group care, and culturally and linguistically appropriate care;

iii. Payment system is structured to reward quality and improved patient outcomes and experience of care;

iv. Funds interdisciplinary collaboration between behavioral health and primary care providers for patients with complex care needs likely to inappropriately access an emergency department and general hospital for preventable conditions;

v. Funds improved access to dental services for high-risk patients likely to inappropriately access an emergency department and general hospital for untreated dental conditions; and

vi. Has been developed with community input and will be made available for inspection by members of the community served by the ACO.

(b) An ACOs gainsharing plan must include its fee-for-service plan and managed care contracts, and must explain the ACOs clinical and programmatic goals, proposed savings calculations, plan for distributing savings, and the ACOs expected use of savings.

(c) Except as provided under the Open Public Records Act, N.J.S.A. 47:1A-1 et seq., an ACOs gainsharing plan, including exhibits and attachments, will be considered a government record subject to the Open Public Records Act upon submission of such plan to the State for approval. However, reimbursement or rate information, including individual unit costs, or provider fee schedules between an ACO provider and a managed care organization, does not need to be included in the gainsharing plan. If applicants include such information in a gainsharing plan, that information may be redacted in accordance with the Open Public Records Act.

(d) A gainsharing plan submitted to the Department shall include the following elements:

1. The ACO must explain how the Demonstration Project objectives will be achieved, including the implementation plan the ACO will follow and the independent benchmarks the ACO will use to measure the success of each objective. Important care approaches and/or techniques to be included in the gainsharing plan include:

i. The use of multidisciplinary teams to coordinate patient care across members of the ACO, including care coordination of patients with chronic diseases and the elderly;

ii. Expansion of the medical home and chronic care models by participating ACO members;

iii. The improvement of access to services for primary care;

iv. The encouragement of patient and/or family health education and promotion, home-based services, and telephonic and web-based communications, group care, and the use of culturally and linguistically appropriate care;

v. Programs to increase patient medication adherence and the use of medication therapy management services;

vi. Plans to use health information technology and share health information across the ACO to improve outcomes and the patient care experience;

vii. Strategies to use open access scheduling in clinical and behavioral health care settings to increase patient access to services;

viii. Programs to promote healthy lifestyles, prevention and wellness activities, smoking cessation, improved nutrition, developing skills in help-seeking behavior, self-management and illness management, and reducing substance use;

ix. A plan to improve service coordination to ensure integrated care for primary care, behavioral health care, dental, and other health care needs, including prescription drugs.

x. An assessment of the expected impact of revenues on hospitals that agree to participate, including estimates for changes in both direct patient care reimbursement and indirect revenue, such as disproportionate share payments, graduate medical education payments, and other similar payments. The assessment shall include a review of whether participation in the Demonstration Project could significantly impact the financial stability of any hospital through rapid reductions in revenue and how this impact will be mitigated. The assessment shall be based only on publicly available data and ACO members shall not share confidential revenue and rate information among themselves while conducting the assessment.

2. The gainsharing plan shall include a letter of support from all participating hospitals in order to be accepted by the Department.

3. Regarding quality standards and reporting, the ACO gainsharing plan shall set forth:

i. The quality measures the ACO will meet.

(1) The ACO shall use the quality measures determined or approved by the Department to measure its health and quality outcomes.

(2) The ACO must select at least five quality performance measures that each participating practice shall use and report on. These measures must provide a valid mix of preventive measures, at-risk population measures, and appropriate use of providers and access to care measures by which the ACO will gauge quality performance and efficiency; and

ii. The quality performance standard levels the ACO intends to achieve at the practice level and at the ACO level for each year of the Demonstration Project, as follows:

(1) For the first year following certification, the quality performance standard shall be at the level of structured and routine reporting by the ACO at the practice level and at the ACO level.

(A) To meet the structured and routine reporting standard, the ACO must establish a method for collecting data from each participating provider. For this performance period collecting sampled data from fewer than all of the patients served is acceptable. If sampling is used, a description of the sampling method used and an explanation of its validity must be provided. Quarterly, manual chart reviews are an appropriate way to meet this initial standard.

(2) For the second year following certification, the quality performance standard shall be at the level of complete and accurate reporting of the measures selected under (d)3i(2) above and achieving a relative performance improvement of at least two measures. Relative performance improvement means a percentage improvement at the practice level over the prior year baseline performance. For example, the practice will improve the number of eligible patients receiving mammograms by 15 percent over the baseline performance the previous year.

(A) An ACO will meet the level of complete and accurate reporting if it submits registry data at the patient level for each participating provider.

(B) An ACO will meet the level of relative performance improvement for at least two measures if it improves its own performance in the two areas at the practice level and at the ACO level by a percentage amount set by the ACO in the ACOs gainsharing plan over the practices prior baseline year.

(3) For the third year following certification, the quality performance standard shall be at the level of relative performance for all five measures and absolute performance of at least two measures. Absolute performance improvement means achieving a preset performance metric regardless of baseline performance. For example, a practice must achieve a mammogram completion rate of 60 percent for all eligible patients.

(A) An ACO will meet the level of relative performance improvement at the practice level and at the ACO level if it improves its performance in the five measured areas by an amount set by the ACO in the ACOs gainsharing plan.

(B) An ACO will meet the level of absolute performance at the practice level and the ACO level if it improves its performance to meet a defined quality threshold set by the ACO in the ACOs gainsharing plan.

(4) The Department will review and analyze the ACOs quality measurement plan and annual performance to ensure the ACO is helping to facilitate improvements in health care access and quality while protecting the provision of medically necessary care. If an ACO does not achieve its performance standards, the Department will notify the ACO of the deficiency and provide the ACO with the opportunity to implement a corrective action plan. The Department has the authority to hold all or a portion of the ACOs shared savings payments in escrow or to have a managed care payer hold all or a portion of their shared savings payments until the ACO corrects its performance measure deficiency.

4. The gainsharing plan must explain how patient experience findings regarding the promotion of improved health outcomes and quality of care will be collected, analyzed, and acted upon, including:

i. The type of tools to be used to collect this information. Appropriate tools include the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey or similar survey instruments, valid patient care experience measurement tools, interviews, and other recognized and accepted methods;

ii. How often the information will be collected;

iii. Who will collect the information and their qualifications for conducting this work;

iv. How the findings will be summarized for reporting purposes; and

v. If the applicant proposes to sample fewer than all of the patients served, a description of the sampling method used and an explanation of its validity.

5. Collecting and analyzing patient and consumer feedback is the best mechanism to detect and remediate any potential improper limitations in care. The gainsharing plan must explain how patients will be provided with improved healthcare quality and access and be protected from improper provider self-referrals, as well as inappropriate reductions or limitations in patient care or services. The ACO must report annually to the Department and the public on the number of complaints received at a provider/practice level, the types of complaints received, and the resolutions implemented. To develop its report and to ensure appropriate care and service are being provided, an ACO must:

i. Provide a clear and easy way for patients or consumers to make complaints or speak up regarding a possible improper provider self-referral, or reduction or limitation of services by a participating ACO member. The mechanism for collecting complaints may include the use of on-line feedback forms, hard copy documents, and/or a telephone "hotline";

ii. Provide a timely process for reviewing and addressing complaints. The ACO shall track and review complaints and have a process by which it direct complaints to the ACO and/or to an individual provider or practice for resolution.

(1) The ACO must ensure that its members put into practice a process for responding to complaints;

iii. Document, at the practice level, instances in which a self-referral, or a reduction or limitation of care is appropriate because the care provided is more effective, will result in better outcomes, and/or is medically appropriate; and

iv. Through its medical director, quality committee, or other governance structure, monitor each participating ACO members provision of care and take appropriate disciplinary actions, which may include withholding gainshare savings in a given year or excluding a practice from the ACO, if a provider improperly reduces care, limits services, or engages in inappropriate self-referral.

6. An ACO must determine how its activities will have an impact on the revenues of each participating hospital over the life of the Demonstration Project and shall share this assessment with the Department of Health and the Health Care Financing Authority. The assessment shall include estimates for changes in direct care patient reimbursement and indirect revenue, such as disproportionate share hospital payments, graduate medical education payments, and other similar payments for each participating hospital. The assessment shall also indicate whether a hospitals participation will have a significant impact on the financial stability of that hospital through rapid reductions in revenue. The assessment only shall be based on publicly available data and ACO members shall not share confidential revenue and rate information among themselves while conducting the assessment.

7. The following provisions apply regarding shared savings:

i. A key component of the Medicaid ACO Demonstration Project is the availability of incentives to providers in a designated area who promote Demonstration Project objectives. Shared savings payments to the ACO are intended to lessen the States Medicaid burden by reducing the amount of unnecessary and inefficient care that is provided to Medicaid beneficiaries. The economic benefit of the shared savings payment is expected at a minimum to be proportional to the benefits and contributions the ACO makes to improving health care quality and reducing costs within its designated area.

ii. An ACO may seek to pursue shared savings in phases. For example, an ACO may choose to focus on shared savings in a specific spending area, such as diabetes treatment for the first year of the project. By the final year of the project, the ACOs gainsharing plan must identify savings for all Medicaid costs within the designated area.

iii. A gainsharing plan must describe how savings earned by the ACO will be used to meet the Demonstration Project objectives. Acceptable uses for shared savings include:

(1) Expenditures that reward quality and improve patient outcomes and care experience, for example, funding activities not otherwise reimbursed, such as exercise classes, weight loss programs, and group and peer education classes;

(2) The funding of interdisciplinary collaboration activities between providers for complex patients, including activities like case conferencing;

(3) Spending funds to improve dental services and access for high risk patients in the ACO area;

(4) Expenditures that expand nursing, primary care, and behavioral health services in the ACO area, for example, funding staff and services to transition primary care practices to the medical home model;

(5) Spending funds to support the infrastructure of the ACO, so that it may achieve its mission and expand the scope of its activities; and

(6) Expanding the nursing, primary care, behavioral health care, and dental workforces and services in the area served by the ACO.

iv. The ACO must explain in its gainsharing plan how it proposes to allocate the savings earned by the ACO to: the State, the ACO, and any voluntarily participating Medicaid managed care organization (if the plan includes any managed care contracts). The percentage of savings allocated to each entity is public information.

(1) To be approved, the gainsharing plan must allocate the savings as follows:

(A) To the State, a meaningful portion of the savings and support the ongoing operation of the Demonstration Project;

(B) To the ACO, a sufficient portion of the savings for the ACO to achieve its mission and expand its scope of activities; and

(C) To the managed care organization, if any, a share of the savings that is proportional to the benefits or contributions the managed care organization provides to the ACO.

(2) With respect to managed care contracts, the ACO shall submit a separate Medicaid managed care organization gainsharing plan to the Department for review and approval. It is expected that an ACO may negotiate different savings allocations with different managed care organizations. The Department will independently review the savings allocations within each ACO-managed care contract to ensure that the agreement is in furtherance of the Demonstration Project objectives. The savings allocation of each contract will not affect the review or analysis of savings allocations in other contracts or the ACOs Medicaid fee-for-service program.

(A) The ACO must attach all of its managed care contracts as exhibits to the proposed gainsharing plan.

(B) Managed care organizations may establish contracts with multiple ACOs. Each MCO-ACO contract may be unique, so long as it meets the requirements of this chapter.

(C) While methods for calculating shared savings and specific provisions may vary in each MCO-ACO contract it is anticipated that over time best practices will be identified and a standardized MCO-ACO contract template and methodology will be developed. This will allow more rapid adoption and spread of the Demonstration Project to new communities.

v. The following provisions apply regarding distribution of savings among participating ACO members. The ACO can choose to pool its shared savings rather than make a distribution to the participating ACO members. However, should the ACO decide to distribute its shared savings, the gainsharing plan must explain how the ACO will divide the savings among its membership. The distribution method must be approved by the ACO governance board in accordance with the ACOs bylaws.

(1) The distribution method must be metric-driven, objective, and supported by data.

(A) Appropriate criteria to consider in determining the distribution method should include the level of achievement of quality performance standards by a member as determined by the Department.

(2) Savings shall be distributed in accordance with an approved gainsharing plan.

(A) The Department expects that the act of distributing savings or pooling of savings may raise conflict-of-interest concerns for the ACO. An ACO shall have a conflict-of-interest policy and shall address conflict-of-interest concerns including the distribution or pooling of savings pursuant to its policy.

(3) The distribution method must be calculated to produce results consistent with the Demonstration Project objectives.

(4) The distribution method must not provide direct or indirect financial incentives for the reduction or limitation of medically necessary and appropriate items or services provided to patients under a health care providers clinical care.

(5) The distribution method must not provide direct or indirect financial incentives for provider self-referrals in violation of Federal law (42 U.S.C. § 1395nn) or State law (N.J.S.A. 45:9-22.5) or reward providers based on the volume of referrals.

8. The ACOs gainsharing plan must explain how cost savings will be calculated, using the following basic methodology:

i. The gainsharing plan shall define a benchmark period against which cost savings can be measured on an annual basis through the Demonstration Project. The benchmark period must be a defined period of time with specific start and end dates that are no more than three years before the beginning of the Demonstration Project. The benchmark period must be long enough to yield a statistically stable measurement.

ii. The gainsharing plan must include a calculation of the expenditures per recipient by the Medicaid fee-for-service program during the benchmark period.

(1) The basic benchmark period expenditures shall be adjusted for characteristics of recipients and local conditions that predict future Medicaid spending but are not amenable to the care coordination or management activities of the ACO and for other factors that affect Medicaid spending in ways that are unrelated to ACO activity. The intent is to share savings based on work performed and outcomes achieved and eliminate random or uncontrollable events in the benchmark calculations. For example, a change in the mix of case severity, changes in Medicaid eligibility, or other factors or events that affect the fair distribution of savings may be risk adjusted within the benchmark payment calculation methodology.

(A) All risk adjustments, and the assumptions used to determine the adjustments applied, must be clearly documented in the ACOs gainsharing plan.

(2) The benchmark savings calculation shall remain fixed for the life of the Demonstration Project.

iii. The method for calculating savings shall compare the expenditures during the benchmark period (that is, the benchmark payment calculation) with expenditures during each year of the Demonstration Project.

9. The Act expresses the intent to include public comment in the ACOs gainsharing plan development process. The public comment process shall include:

i. The availability for inspection by members of the public, in-person at reasonable business hours and where feasible on-line of the following: the ACOs application, Certificate of Incorporation, bylaws, and gainsharing plan. Individuals should be permitted to obtain a copy of these documents at minimal cost, which shall be no more than the cost to request a copy of a government record pursuant to the Open Public Records Act, N.J.S.A. 47:1A-1 et seq.

ii. The availability of the ACOs gainsharing plan for inspection by the public at the offices of the consumer organizations that participate on the ACOs governing board, and on-line where feasible.

iii. A public meeting held by the ACO at which time the proposed gainsharing plan is reviewed by members of the ACO governing board and members of the public are permitted to comment. The ACO shall maintain meeting minutes and the meeting sign-in sheet to verify this process.

iv. A statement in the gainsharing plan that summarizes the community comments received by the ACO, whether such comments were incorporated in the gainsharing plan submitted for approval, and, if not, why such comments were not accepted.

v. Distribution of a summary of the ACOs gainsharing plan in terms that are understandable to the public and in a language that is appropriate to the community that the ACO serves. Such summary should explain the manner in which health outcomes, quality, care coordination, and access are to be improved by the ACO, and the manner in which cost savings are to be achieved and distributed as gainsharing payments. The identities of the practices the ACO expects to be eligible to receive distributions shall be specified. The ACO must also identify the purposes for which it intends to use gainsharing payments. The percentage of cost savings to be distributed to the ACO, retained by any voluntary participating Medicaid managed care organization, and retained by the State, shall be included in the summary of the gainsharing plan.

10. Nothing in (d)9 above prohibits an ACO from establishing additional methods to engage the community in the affairs of the ACO and the development of its gainsharing plan.

(e) The following provisions apply regarding the Departments review of a gainsharing plan:

1. Pursuant to (a)1 above, the Department will independently review, evaluate, and accept or reject each ACO gainsharing plan.

i. Upon receipt of an ACO gainsharing plan, the Department shall post the plan on its website and provide for a 30-day public notice and comment period on the plan. The Department shall review any public comment regarding the plan that is submitted by the deadline.

2. The Department will review, analyze, and verify the gainsharing plan materials, including all attachments and public comments received. The Department may request additional documentation or explanations necessary to conduct its review.

3. The Department shall issue a decision in writing to accept or deny the plan. The Departments decision shall set forth the basis, including the factual record compiled by the Department, on which the decision was made, enumerating the manner in which the ACO proposes to meet criteria specified in this chapter, including, but not limited to, whether the gainsharing plan demonstrates that the ACO:

i. Has a sound plan for carrying out the objectives of the Demonstration Project for the length of the project; and

ii. Will monitor compliance with all project requirements and State and Federal laws, including laws designed to protect Medicaid beneficiaries ability to access medically necessary care;

4. The ACO may request an administrative appeal of a denial of its proposed gainsharing plan pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such denial shall take effect immediately, or at such later date as the Department determines.

(f) The following provisions apply regarding amendments to a gainsharing plan.

1. An ACO has an ongoing obligation to notify the Department of any material changes to its gainsharing plan.

2. If an ACO notifies the Department of a material change to its gainsharing plan materials during the approval process or following approval, the Department shall, in writing, acknowledge receipt of the notice and advise the ACO of what action, if any, it needs to take. The Department may suspend its gainsharing plan review, request additional information from the ACO, require reconsideration or resubmission of the gainsharing plan, decertify the ACO, or take other actions consistent with its authority under the Act or this chapter. The ACO may request an administrative appeal of a decertification action pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such action shall take effect immediately, or at such later date as the Department determines.

N.J. Admin. Code § 10:79A-1.6

Amended by 46 N.J.R. 791(a), effective 5/5/2014.