Why should I join the UT Health San Antonio Regional Physician Network?

The benefits of choosing UT Health San Antonio as your ACO partner cover many different categories of health care.  Besides giving you direct access to our 800 specialists, UT Health is committed to helping you improve care and cut costs in this rapidly evolving health care landscape.

To support ACO practices, UT Health San Antonio utilizes a medical management team of nurses, social workers, and Quality Information Specialists. This team supports care coordination initiatives as well as quality improvement opportunities.

How can I participate in the UT Health San Antonio Regional Physician Network™ ACO?

Simply contact Adam Kirking or Dr. Edward Sankary, who will meet with you and walk through the details. Our ACO phone number is 210-450-8366, you can also contact Adam on his cell phone directly at 715-579-8823.

More FAQs

What is “MACRA”?

MACRA stands for Medicare Access and CHIP Reauthorization Act.  Passed in 2015, it established the Quality Payment Program (QPP) for eligible clinicians, which is administered by the Centers for Medicare and Medicaid Services (CMS) or simply “Medicare” for short.  MACRA and the QPP are the basis for the creation of various value-based care and shared-saving programs.

What is the Medicare Shared Savings Program (MSSP)?

The Shared Savings Program is an Alternative Payment Model (APM) that offers providers and suppliers (e.g., physicians, hospitals, and others involved in patient care) an opportunity to create this new type of health care entity known as an Accountable Care Organization (ACO).

An ACO agrees to be held accountable for the quality, cost, and experience of care of an assigned Medicare fee-for-service beneficiary population. The Shared Savings Program has different tracks that allow ACOs to select an arrangement that makes the most sense for their organization.  Learn more about the program by visiting the CMS website.

What are MIPS and APMs?

Under the Quality Payment Program, eligible clinicians can participate via one of two tracks: Alternative Payment Models (APMs); or the Merit-based Incentive Payment System (MIPS).

MIPS and APMs are both value-based programs and designed to incentivize physicians to improve patient care.

An APM is “a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.” (From CMS Website, click to read more on APMs.)

An Accountable Care Organization (ACO) is a type of APM.

MIPS is based on existing Medicare programs, including: the Physician Quality Reporting System, the Medicare Electronic Health Record Incentive Program and the Value-Based Payment Modifier.  These programs are all now bundled under the title Quality Payment Program (QPP).  There are incentive thresholds in these programs that reward improved outcomes, as well as baselines that lower reimbursement for lower-quality outcomes.

Though MIPS and APM programs vary in process details, the quality measures are very similar.  The key difference between the two is an APM exposes the provider to greater financial risks, but also the potential to receive greater financial rewards.  In an APM, the financial incentives are tied not only to the quality of care provided, but also to the level of financial risk taken by the group.

MIPS processes are used for quality metrics reporting, and the UT Health San Antonio Regional Physician Network™, which is applying to CMS to be an Accountable Care Organization (ACO), will be an “MIPS APM”.

Obviously, this can all be very confusing, which is why we simply refer to our entity as an ACO.

Who is subject to MIPSs & APMs and what are the implications to my practice?

The implications to all physicians and practices are far-reaching.  CMS is transitioning to a system where eventually, all payments will be quality-based. The phased approach began in 2017 and has different criteria for different sized physician groups and practices.  Eventually, all providers seeing Medicare patients will need to choose between the different payment models for Medicare reimbursement.

What factors determine a clinicians MIPS score?

As prescribed by MACRA, MIPS focuses on the following: (1) quality—including a set of evidence-based, specialty-specific standards; (2) cost; (3) practice-based improvement activities; and (4) use of certified electronic health record (EHR) technology (CEHRT) to support interoperability and advanced quality objectives in a single, cohesive program that avoids redundancies.

For more, read the “MIPS Scoring Guide” at the CMS Website.

How is the quality performance scored?

To score performance, CMS uses a base of outcomes-related measures, patient satisfaction ratings and information taken directly from claims data for patients, including use of an electronic health record, screening for chronic issues like hypertension and diabetes, hospital admissions and readmissions, as well as patient experience surveys.

CMS will measure the quality of care using 23 nationally recognized quality measures in four key domains:

• Patient/Caregiver Experience (10 measures)
• Care Coordination/Patient Safety (4 measures)
• Clinical Care for At-Risk Population (3 measures)
• Preventative Medicine (6 measures)

The 23 quality measures will be reported and calculated using:
• Medicare claims data (3 measures)
• CMS Web Interface ACO-reported clinical quality measure data (10 measures); and
• Patient experience of care survey data (10 measures).

Read more on scoring at the CMS website.

What are MIPS data submission and audit requirements?

CMS requires the reporting of data for clinicians individually or as a group that bills through a common tax identification number (TIN).  The choice is made consistently across all MIPS performance categories for either a clinician or a group for a performance year.  The choice may be changed once per year.

The following table is a summary of reporting methods (data submission) by MIPS performance category as specified by CMS:

 

Performance Category

Submission Mechanisms for Individuals

Submission Mechanisms for Groups (Including Virtual Groups)

Quality

QCDR Qualified Registry, EHR Claims

QCDR Qualified Registry, EHR,  CMS Web Interface (groups of 25 or more)

Cost

Administrative claims (no submission required)

Administrative claims (no submission required)

Improvement Activities

Attestation, QCDR, Qualified Registry, EHR

Attestation, QCDR, Qualified Registry, EHR, CMS Web Interface (groups of 25 or more)

Promoting Interoperability

Attestation, QCDR, Qualified Registry, EHR

Attestation, QCDR, Qualified Registry, EHR, CMS Web Interface (groups of 25 or more)

MIPS information is subject to audit for up to six years after the associated submission. CMS may audit clinicians or groups and require them to share primary source document that may include patient records.  The focus is on the metrics surrounding quality, cost and advancing care.  Advancing care refers to adopting and using technology to improve care, including categories such as electronic record keeping, IT security and patient communication and education.

As your ACO partner, UT Health does the required data submissions through the CMS portal.

What is the UT Health San Antonio Regional Physician Network (RPN) and how is it different from UT Health Physicians, the practice at the medical school?

The UT Health San Antonio Regional Physician Network is a separate entity, created under the auspices of the UT System, by the UT Health San Antonio Physicians, to maintain, organize and manage the patient care model and data requirements needed to helping patients achieve the benefits of our value-based care model.

Private practice physicians and physician groups may sign on as affiliates of the UT Health San Antonio Regional Physician Network to partner in the processes and share in the rewards of cost-savings with our value-based care model.  This creates many benefits for affiliates, including direct access to the specialists and primary care physicians of UT Health San Antonio.

If I join the UT Health Regional Physician Network / ACO, how is my data gathered and submitted to CMS?

Affiliates of the UT Health San Antonio ACO have the support of the UT Health Quality Team and IT team who collect, organize and prepare data for submission to CMS.  The final submission is supervised and executed by UT Health San Antonio Regional Physician Network via the CMS submission website.

Is my data safe?

Yes.  We employ the latest healthcare software, including the EPIC electronic health record system, and we maintain robust encryption and security protocols, many of which exceed those required by state and federal guidelines.

What if I decide I no longer want to participate?

A simple 90-day notice in writing is all that is required to withdraw from ACO affiliation.

Do I still bill insurance companies and patients normally?

Yes.  There is no need to do anything differently regarding billing.

Since this is a non-profit, what happens if there’s a surplus?

The ACO shares the majority of any surplus with its affiliated physicians.  Please ask your UT Health Regional Physician Network representative for more details.

If the ACO does not meet performance measures, what is my financial risk as an affiliated practice or physician?  

This question is where the ACO model demonstrates one of its core strengths – the concept of more potential gain than risk to the ACO participants, and dilution of risk throughout the total metrics of the organization, including the affiliates.  Specifically, CMS has set the program up to have much more upside potential than risk.  In addition, the risk is then spread throughout, so the ACO as a group is able to minimize the impact on any individual physician or group.