CMS Publishes Final ACO Rule

On Thursday, June 4, 2015, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Shared Savings Program Accountable Care Organization (ACO) final rule. This rule is an effort to encourage the delivery of high-quality care for Medicare beneficiaries and build on the early successes of the program and of the Pioneer ACO Model.  It is all part of CMS’ goal to provide support for the provider community in creating a delivery system with better care, smarter spending, and healthier people.  The final rule is available online.

Overall, the final rule increases the emphasis on primary care services in the beneficiary assignment methodology and streamlines data sharing to provide improved access to the data necessary for ACO operations such as quality improvement and care coordination, while maintaining beneficiary protections.  This rule also adds a new performance-based risk option (Track 3) that includes prospective beneficiary assignment, a higher sharing rate, and the opportunity to use new care coordination tools.  In Track 3, the rule also establishes a waiver of the 3-day stay Skilled Nursing Facility Rule for beneficiaries prospectively assigned to ACOs, which would permit payment for otherwise-covered SNF services when a prospectively-assigned beneficiary is admitted to a SNF without a prior 3-day inpatient stay.

In terms of participation agreement renewals, this rule allows eligible ACOs to continue participation under the one-sided model (Track 1) for a second agreement period with the same sharing rate (50 percent) as was available to them under the first agreement period.  Under Track 2, CMS is modifying the existing two-sided performance-based risk track so an ACO will have the choice of several symmetrical minimum savings rate/minimum loss rate options that will apply for the duration of its 3-year agreement period. 

CMS is also refining the methodology for resetting the benchmarks to help ensure that the program remains attractive to ACOs and continues to provide incentives for ACOs to improve efficiency and quality of care, in addition to generating savings for the Medicare Program.  Specifically, the rule resets the benchmark in a second or subsequent agreement period by integrating previous financial performance and equally weighting benchmarks for subsequent agreement periods.

The full rule available online