On June 9, 2015, the Centers for Medicare and Medicaid Services (CMS) published this final rule that significantly revises the requirements for the Medicare Shared Savings Program accountable care organizations (ACOs) established through section 3022 of the Affordable Care Act (ACA). Since the implementation of the Medicare Shared Savings Program in 2012, there are now over 400 ACOs participating in the program, serving over 7.3 million Medicare fee-for-service beneficiaries.
In a fact sheet accompanying the publication of the final rule, CMS summarizes the major changes to the program:
- Increasing the emphasis on primary care services in the beneficiary assignment methodology and adding nurse practitioners, physician assistants, and clinical nurse specialists as primary care providers;
- Streamlining data sharing to provide improved access to data necessary for accountable care organization (ACO) health care operations such as quality improvement and care coordination, while maintaining beneficiary protections;
- Adding a new performance-based risk option (Track 3) that includes prospective beneficiary assignment and a higher sharing rate;
- Providing ACOs choice of symmetric threshold for savings and losses under performance-based risk tracks;
- Addressing participation agreement renewals including allowing eligible ACOs to continue participation under the one-sided model (Track 1) for a second agreement period;
- Establishing a waiver of the 3-day stay at Skilled Nursing Facilities rule for beneficiaries that are prospectively assigned to ACOs under Track 3;
- Refining the methodology for resetting benchmarks to help ensure that the program remains attractive to ACOs and continues to provide strong incentives for ACOs to improve the efficiency and quality of patient care, and generate savings for the Medicare Trust Funds; and
- Refining eligibility, ACO governance, and other requirements, including a streamlined process for current Pioneer ACOs to convert to Medicare Shared Savings Program ACOs.
While most of these changes focus on the methodologies for calculating the shared savings available to program ACOs, there are significant changes to Medicare beneficiary assignment, notice, and opting out of data-sharing that are important from a beneficiary perspective.
CMS did not resolve all the potential issues on adjusting benchmarks for the shared savings calculations on a regional rather than individual ACO basis, deferring those decisions to additional rulemaking expected later this fall.
It is expected that these changes will encourage existing program ACOs to renew their participation for additional three-year cycles, as well as encourage additional health care organizations to apply to join the program.
One important technical note is that this is the first time that CMS has used its authority under ACA section 3021 to certify that elements of a Center for Medicare and Medicaid Innovation Program, the Pioneer ACO model, has demonstrated sufficient quality improvement and cost reduction to be applied to other CMS programs, such as this Medicare Shared Savings Program.
Ignatius Bau 