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BREAKING: CMS Publishes New ACO Regulations

December 1, 2014
by Gabriel Perna
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CMS Doubles Down on Two-Sided Risk

The Centers for Medicare and Medicaid Services (CMS) has released its proposed changes to its established accountable care organization (ACO) programs, including updated provisions around financial risk, and the creation of an entirely new third category for ACO participation, outside of the existing Medicare Shared Savings Program (MSSP) and the Pioneer ACO Program, under the rubric "Track Three."

In the 429-page rule, CMS aims to get more healthcare organizations to take on greater risk through ACOs, while also try to amend many of the problems that have plagued those in the current programs.

The proposed changes include the introduction of the new two-sided risk ACO called Track Three, which will integrate elements from the Pioneer ACO program, such as higher rates of shared savings and prospective attribution of beneficiaries. In exchanging for going with the new two-sided risk model, ACOs will be given a longer lead time to transition including one-sided risk in the first agreement period. They also can go with this without having completed a prior agreement under a one-sided model. Ultimately, the new model – being called “Track Three” – will include more risk, but more savings for participants, specifically up to 75 percent savings based on quality performance.

The prospective attribution change will give ACOs a list of assigned beneficiaries at the start of the performance year and will not add anyone else during the course of the year.  This is an attempt by CMS to quell many of the concerns that current ACOs have faced on patient attribution. The agency is also changing the way beneficiaries are assigned, making it easier for patients to know when they are in an ACO. CMS has done this by removing ACO assignment to certain specialty types whose services are not likely to be indicative of primary care services.

Furthermore, CMS is looking to incentivize more inclusion in the two-sided risk programs, whether it be the new “Track Three” or the Pioneer ACO program.  They say they have done this by waiving restrictions telehealth and providing more flexibility around post-acute care referrals. The agency is also attempting to streamline the process for ACOs to access beneficiary claims data necessary for operations, including sets on quality improvement activities and care coordination. They’re also giving beneficiaries the chance to decline to have their claims data shared with the ACO.

According to Kaiser Health News, CMS is also allowing current ACOs to delay penalties for three years, but making them earn less in shared savings by doing so.

These changes come after tumultuous year for CMS’ Pioneer ACO program, with many participants having trouble saving money and many opting to drop out. The MSSP currently includes more than 330 ACOs in 47 states, providing care to more than 4.9 million beneficiaries in Medicare fee for service.

Healthcare Informatics will have more on this story as it develops.

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