The Centers for Medicare and Medicaid Services (CMS) has published a proposed regulation that would make significant changes to the Medicare Shared Savings Program Accountable Care Organizations (ACO). This is the only ACO program specifically authorized by Congress in the Affordable Care Act (section 3022), although CMS has supported additional ACO models such as the Pioneer ACOs through the Center for Medicare and Medicaid Innovation, and Medicaid ACOs through state plan amendments, section 1115 waivers, and State Innovation Model grants. There are over 330 Medicare Shared Savings Program ACOs operating in 47 states, the District of Columbia, and Puerto Rico, covering about 4.9 Medicare beneficiaries. An announcement about a next round of Medicare Shared Savings Program ACOs (to begin January 1, 2015) is also expected.
Among the proposed changes are:
- Allowing Medicare Shared Savings Program ACOs to continue with the “Track 1” shared savings, but no risk of losses, for another three years (for a total of five years) rather than being required to use “Track 2” shared savings AND shared risk for losses
- Including nurse practitioners, physician assistants, and clinical nurse specialists as primary care providers for beneficiary assignment, and removing certain specialists as providers for beneficiary assignment
- Changing the “opt-out” process for ACO beneficiaries who do not want their data shared with the ACO to only require posted signs at points of care (rather than individual written notices/letters), and requiring beneficiaries to call 1-800-Medicare to opt out
- Using regional rather than national Medicare expenditure data to set benchmarks for shared savings (and shared losses) and re-setting the benchmarks based on the regional market and ACO performance
- Offering the option of a “Track 3” with potential for higher shared savings, using prospective beneficiary assignment (rather than the current retrospective reconciliation)
- Modifying the “Track 2” shared savings, shared losses formula to make it more variable
The proposed changes also include changes to the governance and leadership requirements for Medicare Shared Savings Program ACOs (e.g., no longer requiring the ACO medical director to be an ACO provider). Finally, in recognition of the mixed success of the Pioneer ACOs, the proposed changes include a streamlined process for transitioning Pioneer ACOs into the Medicare Shared Savings Program.
Comments are due February 6, 2015.