CMS Releases New Medicare Shared Savings Program Accountable Care Organization Proposed Rule

On Monday, December 1, 2014, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule on the Medicare Shared Savings Program (MSSP) and Accountable Care Organizations (ACOs).  This proposed rule would make changes to the regulations that were promulgated in November 2011 to implement the Shared Savings Program.  CMS is making refinements in this rule based on its experience with the program as well as to respond to concerns raised by stakeholders. Comments on this proposed rule will be due on February 6, 2015.

CMS used the proposed rule publication to tout some of the current successes of the MSSP, including that there are more than 330 ACOs and more than 125,000 Medicare enrolled practitioners participating in the program. These ACOs function in 47 states, in addition to Washington, DC, and Puerto Rico and roughly 4.9 million beneficiaries are assigned to these ACOs (although, while assigned, such beneficiaries are free to seek services from non-ACO providers under traditional Fee-For-Service Medicare).

The proposed changes by CMS would be effective 60 days after publication of the final rule.  Application or implementation dates may vary, but CMS anticipates all final policies and methodological changes would be applied for the 2016 performance year for all participating organizations unless the agency notes otherwise.

The proposed rule also highlights the importance of health IT to the development of ACOs.  CMS states that future applicants to the program should be able to explain how they will develop the health IT tools and infrastructure to accomplish care coordination across and among physicians and providers. CMS cites the adoption of health IT as important for supporting care coordination by ACO participants and other providers outside the ACO in the following ways: 

  • Secure, private sharing of patient information;
  • Reporting on quality data and aggregating data across providers and sites to track quality measures; and
  • Deploying clinical decision support tools that provide access to alerts and evidence based-guidelines.

Moreover, the proposed rule discusses how as ACOs establish more mature processes for risk management, IT infrastructure allows ACOs and providers to conduct robust financial management of beneficiary populations, deliver cost and quality feedback reporting to individual providers, and streamline the administration of risk-based contracts across multiple payers. CMS emphasizes the importance of requiring ACOs to address health IT infrastructure in their application to the Shared Savings program to support more careful planning and increased focus on this issue. 

The major changes that CMS is proposing include:

  • Participation Agreement Renewal Requests
    CMS is proposing to that ACOs that want to continue in the next iteration of the program may have some flexibility in which track they can pursue.  Current regulations require that ACOs participating in Track 1 (sharing savings, but not losses) may continue in the program after their initial 3-year agreement period only if they enter a performance risk-based (two-sided) track.  CMS is proposing to take into account such things as the ACO’s history of compliance with the requirements of the Shared Savings Program and the ACO’s history of meeting the quality performance standard during the first 2 years of program participation. Additionally, the agency is proposing to permit ACOs to participate in one additional agreement period under Track 1, but at a lower sharing rate than the previous agreement period to encourage progression along the performance risk continuum.
  • Greater Flexibility for ACOs to Utilize Telehealth Services
    CMS proposes to give ACOs more flexibility to use reimbursable telehealth services, but the agency does not propose to completely waive Medicare telehealth rules.  CMS poses a number of questions for ACOs and stakeholder organizations to answer in their public comments on this issue.  He proposed rule does discuss how the use of remote access technologies may improve the accessibility and timeliness of needed care, increase communication between providers and patients, enhance care coordination, and improve the efficiency of care. CMS does acknowledge that ACOs and other commenters have suggested that a waiver of certain Medicare telemedicine payment requirements would help encourage a broader range of ACOs to more fully utilize telehealth, remote patient monitoring, and other such enabling technologies.
  • Streamlining the Process for ACOs to Access Beneficiary Claims Data
    CMS is proposing that ACOs would provide written notification at the point of care through signs posted in their facilities that include template language regarding data sharing and the opportunity for beneficiaries to decline data sharing by calling 1-800-Medicare.  CMS wants to ease the burden on ACOs to access beneficiary claims data necessary for health care operations while retaining the opportunity for beneficiaries to decline to have their claims data shared with an ACO.
  • Resetting ACO Financial Benchmark
    CMS is asking for comments on a number of alternative methodologies for establishing, updating, and resetting ACO financial benchmarks. For example, the agency is interested in hearing reactions to potentially using regional fee-for-service (FFS) expenditures instead of national FFS expenditures in establishing and updating the benchmark.  Moreover, CMS wants to hear comments on transitioning to using regional FFS cost data to make ACO benchmarks gradually more independent of the ACO’s past performance and gradually more dependent on the ACO’s success in being more cost efficient relative to its local market.