CMS Proposes to Completely Overhaul Accountable Care

CMS announced a major proposed adjustment to the vast majority of Accountable Care Organizations on Thursday, August 9 by re-branding the Medicare Shared Savings Program (MSSP) as the “Pathways to Success Initiative.” In essence, CMS Administrator Seema Verma intends to shorten the period in which Medicare ACO’s can reap shared savings without being on the hook for exceeding cost targets. Currently, 460 out of 561 of Medicare’s MSSP ACO’s are upside-only, risk-free arrangements that eligible clinicians and health systems alike can enjoy for up to 6 years. The highly anticipated proposed rule includes varying implications depending on your organization’s status towards value-based care, as defined by CMS.

Proposed Adjustments include:

• The Track 1, 2, 1+ and 3 MSSP ACO’s will be replaced by two new, more self-explanatory track names: BASIC and ENHANCED.
• The BASIC TRACK entails a “glide path” which essentially phases a one-sided models into higher levels of risk. ACOs start with two years of upside-only risk before gradually accepting further shared risk until they finally receive a level of risk that qualifies them as Advanced Alternative Payment Models (APMs) as defined by the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
• The ENHANCED Track provides two-sided risk immediately, qualifying organizations as an APM, similar to the current Track 3 MSSP.
• All Agreement periods will be five years, replacing the current 3 year MSSP arrangement.
• The potential to allow beneficiaries to “opt-in” to the ACO for beneficiaries to choose to be attributed to an ACO.

Notable Points for current MSSP Participants:

• Current Track 1, 2, or 1+ MSSP’s may finish their current contracts or apply to immediately participate in a BASIC or ENHANCED track.
• Current ACO’s will be able to remain in an upside-only risk arrangement for one more year before accepting further risk in the BASIC Track.
• CMS is proposing an offer to allow ACO’s with a participation agreement ending in 2018 to extend their current contract through June 30^th, 2019 and apply to participate under either the BASIC or ENHANCED Track.
• “MIPS APMs” will experience a push towards the Advanced APM scoring standards or divert to the MIPS program scoring standards.

Notable policy implications of the Pathways For Success Initiative:

• Prospective Beneficiary assignment with retrospective reconciliation each measurement period will be utilized.
• Regional spending targets rather than current national medical cost trend benchmarks.
• Eligible clinicians will be able to receive telehealth reimbursement, even when current geographic limitations haven’t been met.
• Continuation of the skilled nursing facility 3-day waiver currently available to Track 3 participants.
• Requiring written notices to be provided to beneficiaries during their first primary care visit in a performance year. This intends to drive patient understanding and engagement with the care they will receive in the ACO.
• Offering beneficiary incentive payments up to $20 for receiving qualifying primary care services.
• Require a certain percentage of eligible ACO participants to adopt 2015 certified EHR technology (CEHRT).

Stay tuned for the final rule expected later this fall. Please review further detail regarding the Proposed Rule’s impact on MIPS participants or APM participants or contact our office.