Value-Based Care News

CMS Released Proposed Rule for Accountable Care Organizations

When it comes to accountable care organizations choosing to participate in a risk-based arrangement, the proposed rule allows for a “participation option.”

By Vera Gruessner

- Last week, the Centers for Medicare & Medicaid Services (CMS) announced a new proposed rule that would revise the formula used to analyze the performance of accountable care organizations participating in the Medicare Shared Savings Program. The proposal is meant to stimulate more long-term solutions for keeping MSSP accountable care organizations in operation.

Medicare Shared Savings Program

In particular, the proposed rule incentivizes ACOs on a more long-term basis if the providers continue to ensure quality and efficient care for Medicare beneficiaries. CMS is looking to revise the methodology for resetting benchmarks among accountable care organizations. The benchmarks are meant to measure ACO performance for those organizations looking to renew their participating in the Medicare Shared Savings Program for an additional year.

“Medicare payments are an important catalyst to improving care delivery, spending our resources smarter and keeping people healthy,” Andy Slavitt, Acting Administrator for CMS, said in a statement. “This proposal allows ACOs in all parts of the country to be successful by recognizing both their achievements and improvements in how they provide care. This should have the effect of growing the number of ACOs, and making ACOs and the coordinated care they provide to patients, more of a standard in all parts of the country.”       

The proposed rule from CMS looks to adjust a benchmark associated with regional spending, which will become part of the quality performance measurement throughout a handful of agreement periods.

Essentially, the new methodology would allow accountable care organizations to have their healthcare spending growth be dependent upon regional factors instead of a national framework. Additionally, there will be more focus on an ACO’s historical spending rates and spending in the regional service area in order to boost continued participation in the Medicare Shared Savings Program.

The proposed rule is also looking to incorporate more of a phase-in approach when it comes to implementing some of the quality measures among ACOs, which should give providers more time to prepare and improve performance.

When it comes to accountable care organizations choosing to participate in a risk-based arrangement, the proposed rule allows for a “participation option” in which ACOs can choose to exist in their current framework during the fourth year of operation and defer for one more year before pursuing a performance-based risk methodology.

In addition to the “participation option,” CMS is seeking to clarify the timeline and requirements related to determining ACO shared savings payments. The proposed rule from CMS is based on a wide variety of input provided by stakeholders over the last year.

This particular proposed rule is meant to revise the analysis of benchmarks among accountable care organizations that have already participated in the Medicare Shared Savings Program for a three-year period. The proposal also moves forward to extend some of the clarifications sought from the June 2015 Shared Savings Program final rule. CMS had previously committed to further rulemaking with regard to modifying the methodology behind some of these benchmarks.

The modifications are expected to move ACOs from the initial MSSP arrangement toward performance-based risk arrangements as well as cut down on administrative burden and boost transparency, CMS reported.

The federal agency is also looking to transition the Medicare Shared Savings Program into one in which accountable care organizations will “share in both savings and losses” in a performance-based risk model. Stakeholders and the general public have 60 days to comment and provide feedback on this proposed rule.

When it comes to discovering methods that accountable care organizations can take to garner more shared savings in the Medicare program, the President and CEO of the National Association of ACOs Clif Gaus provided some perspective.

“In my view, the most important road to success is finding ways to coordinate and manage post-acute care and hospital care. One – trying to avoid hospitalizations. Two – providing the most efficient and effective post-hospital care through home health agencies. That’s the key to success,” Gaus explained.

“Now what do they need to do that? They need really good, current data on their beneficiaries that are in their ACOs to know what their risks are and to target their services to that high-risk population. Also, they need near real-time or real-time data on the patients when they are hospitalized or show up in emergency rooms. That piece of data, for the most part, is missing in every ACO.”

“The government sits on all of this data. The government knows in real-time when a beneficiary is in the emergency room or being considered for admission to the hospital because hospitals and emergency rooms have to notify the government of that and seek the benefits. The government has refused to help the ACOs in this issue,” Gaus continued.

“We’ve negotiated with the government for almost two years trying to work this out. CMS says that they don’t believe this kind of data will be very helpful to ACOs. Also, they don’t have enough money to provide these notifications to the ACOs. Additionally, they’ve recently ruled that, because an ACO is technically not a provider – ACOs are a collection of providers or partnerships of providers – CMS cannot provide beneficiary-specific data to an ACO.”