ACA Now

Implementation Status

The Medicare Shared Savings Program (MSSP) launched in 2012. For a variety of details regarding the MSSP, including all previously released regulations, FAQs and other guidance, visit the CMS website devoted to the program.

On January 10, 2013, CMS announced 106 new ACOs participating in the Shared Savings, Advanced Payment Model or Pioneer ACO programs. Additional information about the Shared Savings Program is available here.  In a related event, note that CMS, as part of its Medicare & Medicaid Research Review (MMRR) Group collaborative, hosted between February 4-11 an online discussion forum with Rutgers University health economist, Derek DeLia, on how ACOs share savings with Medicare.  Details are available here. 

On April 5, 2013, the Medicare Payment Advisory Commission (MedPAC) received an update on CMS’s current ACO initiatives. Commissioners discussed these models’ designs, as well as ACOs’ strengths, weaknesses and geographic distribution relative to Medicare Advantage (MA) plans.

On June 13, Sen. Ron Wyden (D-OR) delivered a keynote address at a National ACO Summit in which he discussed ACO reforms, noting, for instance, “the attribution rule needs to be changed to allow providers to specialize in chronic care.”

On July 8, CMS released the CY 2014 Physician Fee Schedule proposed rule, part of which, among other ACO-related issues, addresses ACO quality benchmarking issues. On this note, “CMS proposes to includ[e] data submitted by the Shared Savings Program and Pioneer ACOs to set the benchmark for the 2014 performance period.” Also see the accompanying quality-focused fact sheet. Comments are due on September 6, 2013.

On August 9, SAMHSA issued a 10-part technical assistance report, Medicaid Handbook: Interface with Behavioral Health Services, that broadly examines Medicaid’s role in financing mental health and substance abuse care.  Several “modules” that comprise the handbook – which span such topics as Medicaid State Plans and behavioral health service providers – relate to ACA implications; for example, the Medicaid expansion under section 2001; health home initiatives under section 2703; and Accountable Care Organizations under section 3022.

On a related note – but specific to Medicaid – on August 30, CMS disseminated a letter to state officials providing guidance on Medicaid shared savings reimbursement models intending to incentivize improved quality and outcomes while reducing Medicaid program costs.  In particular, the letter providers guidance regarding a number of details states should consider in implementing these models, including: background on standard shared savings reimbursement models; methodologies for distributing payments; actuarial analysis to determine bona fide changes in cost trends; risk- and gain-sharing arrangements; and targeting of specific providers and patient populations.  The letter concludes with a directive to ensure the standard State-Federal share of Medicaid-related expenses is maintained throughout these programs.

On December 20, 2013, CMS announced the Pioneer ACO Model RFI (see here). On January 28, 2014, CMS convened an eHealth provider webinar to provide information on ACOs, with a more extensive discussion of the various ACO models (Pioneer, Advance Payment, Comprehensive ESRD Initiative; and MSSP). See here. On January 30, CMS released interim findings on a number of delivery system reforms underway – including the MSSP and Pioneer ACOs (first-year evaluation report here). A CMS blog post and a press release on these findings are available here and here, respectively.

On January 30, 2014, CMS released interim findings on a number of delivery system reforms underway, including those related to Medicare ACOs, including Pioneer ACOs, as well as (the pre-ACA) Physician Group Practice (PGP) demonstration and the Bundled Payments for Care Improvement (BPCI) initiative. For more information, see here (CMS fact sheet); here (CMS blog post); and here (Pioneer ACO interim evaluation).

CMS intends to hold a National Provider Call (registration) on April 8, 2014 on the application process for the MSSP ACOs’ January 1, 2015 start date. Among other topics, CMS will discuss key application dates (also see the agency’s MSSP homepage) and Notice of Intent to Apply submission, as well as provide time for Q&A. Additional details follow.

On May 6, CMS posted a video pertaining to the Comprehensive ESRD Care Initiative, titled “Making the ACO Business Case.”

On May 8, CMS issued a revised fact sheet, exploring “what providers need to know” about ACOs. The agency also updated its fact sheets on the MSSP final rule (here); MSSP engagement for rural providers (here); CMMI’s Advance Payment Model demo (here); and the methodology for determining shared savings and losses (here).

On June 16, MedPAC submitted comments to the CMS in which the Commission outlined several short- and long-term issues that it believes warrant consideration by the agency as the ACO model evolves. These issues include those that are reconcilable via both administrative action by CMS, as well as others that require a legislative change.

On June 26, CMS sent a proposed rule to the OMB for review that addresses changes to the MSSP and “contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program.” These changes would apply to existing ACOs and approved ACO applicants participating in the program beginning January 1, 2016. This is the final step prior to the promulgation of the rule  in the Federal Register.

On October 2, the OIG issued aproposed rule delineating revisions to Medicare and Medicaid safe harbors under the anti-kickback statute, as well as amendments to civil monetary penalty (CMP) rules pertaining to beneficiary inducements and gainsharing. Comments are due by 5pm ET on Dec. 2, 2014.

On October 8, CMS announced that in 2012, the first Medicare Pioneer ACOs performance year, Pioneer ACOs reduced expenditures for assigned Medicare beneficiaries by as much as 7.1%. Others exceeded cost benchmarks by up to 5.2%. The following year, those remaining in the program posted a similar range of between 7.0% savings and 5.6% losses relative to their benchmark. Also: year 1 and year 2 quality results.

On October 15, CMS announced (fact sheet; FAQs; online application) the availability of up to $114 million in ACA funding to support roughly 75 ACOs participating in the MSSP. This funding – made available in the form of upfront investments (or pre-paid shared savings) under the newly-launched ACO Investment Model (AIM) – builds on theAdvance Payment Model and is intended to support providers who might otherwise lack the capital to make requisite infrastructure changes to form ACOs and to spur current MSSP ACOs “to transition to arrangements with greater financial risk.” CMS clarifies that “[t]he application deadline for organizations that started in the [MSSP] in 2012 or 2013 will be December 1, 2014. Applications will be available in the summer of 2015 for ACOs that started in the [MSSP] in 2014 or will start in 2016.”

On October 16, CMS and OIG issued a joint notice announcing the continuation of the effective date – through Nov. 2, 2015 – of an interim final regulation that permits waivers of specified Medicare fraud and abuse provisions that may be necessary for providers to implement ACOs under the MSSP. Importantly, CMS confirms in the notice that it is “currently developing a proposed rule regarding the [MSSP],” acknowledging stakeholders’ concerns that “certain modifications to the [MSSP] regulations were necessary.” Some preliminary details of this forthcoming proposed rule are available here.

On October 24, CMS posted the updated benchmark methodology report applicable to performance years 4-5 of the Pioneer ACO model. Additional details here.

On October 28, the IRS issued interim guidance to healthcare facilities with tax-exempt bond financing that are participating as ACOs in the MSSP. Comments are due by Jan. 22, 2015.

On Oct. 31, CMS posted the CY 15 Medicare Physician Fee Schedule (MPFS) final rule with comment (fact sheet) addressing a number of ACA provisions related to physician payment and quality. Citing the April 1 doc fix, the Protecting Access to Medicare Act (PAMA) of 2014, CMS notes that a 0.0% update applies between Jan. 1, 2015, and March 31, 2015, for a conversion factor (CF) of $35.8013 during that period (after budget neutrality adjustments). The SGR calculation applies thereafter (April 1, 2015-Dec. 31, 2015), with the final rule conveying a 21.2% payment reduction for this period relative to the CY14 CF, with a CF of $28.2239.

On Dec. 1, CMS issued a proposed rule delineating major changes to the MSSP – methodological and payment policy changes intended to improve the program’s overall construct via a renewed emphasis on primary care and performance-based risk arrangements. In general, the provisions, once finalized and unless otherwise noted, would be applicable for the 2016 performance year for all participating organizations. A CMS fact sheet is available here and a press release here. Comments on the proposed rule are due by Feb. 6, 2015.

On Dec. 1, CMS released (announcement here) a proposal (here) to change several program areas such as beneficiary assignment, data sharing, performance risk models, eligibility requirements, participation agreement renewals, and compliance and monitoring. Also see a corresponding press release (here) and fact sheet (here).

On Dec. 22, CMS announced (blog post here) that 89 ACOs will join the Medicare Shared Savings Program in January, thus bringing the total number of organizations to 405 and increasing the number of beneficiaries impacted from 4.9 million to 7.2 million. See here, for list of new ACOs.

On Feb. 17, CMS updated the application cycle deadlines (see here) for program year 2016 of the MSSP.

On Mar. 19, CMS announced two National Provider Calls to be held on Apr. 7 and 21 (details here) to help providers with the Medicare Shared Savings Program Application process.

On Apr. 1, CMS issued a memo delineating the Notice of Intent to Apply (NOI) process for to prospective MSSP applicants, as well as ACOs renewing for the next three-year agreement period.

On June 4, CMS released a final rule updating the Medicare Shared Savings Program, which, among other changes, establishes a new performance-based risk option (Track 3).

On June 25, CMS updated its eligibility criteria for its ACO Investment Model to allow for large rural Shared Savings Program ACOs and ACOs that have started in 2015 or will start in 2016.

On July 8, CMS posted the CY 16 Medicare Physician Fee Schedule (MPFS) proposed rule, which delineates payment policies impacting over one million physicians and other practitioners paid under the MPFS each year (see fact sheet here). Citing the latest doc fix (P.L. 114-10), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS effectuates the statutory 0.5% increase. The proposed rule addressed this provision of the ACA. Comments are due Sept. 8.

2016

On Jan. 11, 2016, CMS announced the participants in the Next Generation ACO Model (details) and the ACO Investment Model (details).

On Jan. 28, CMS released a proposed rule delineating revisions to the MSSP’s financial benchmarking approach, including the process for trending, adjusting, and updating MSSP accountable care organizations’ (ACOs) expenditure benchmarks and using regional – rather than national – cost trends. The proposals build on CMS’ June 2015 ACO final rule, which sought to encourage ongoing participation in the MSSP, though indicated that additional proposals would be forthcoming on benchmarking issues. Comments are due by Mar. 28.

On May 31, the period for organizations to submit a Notice of Intent to Apply (NOIA) closed for the Medicare Shared Savings Program.

On June 6, CMS released its final rule on incorporating regional fee-for-service expenditures into its approach for establishing, updating, and rebasing the historical benchmarks of Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) following their initial three-year agreement periods. CMS says the changes make the benchmarks, which are the basis for shared savings or losses, “more independent of [an ACO’s] historical expenditures and more reflective of FFS spending in its region” over time. The final rule also addresses the administrative finality of financial reconciliation calculations and provides a new pathway for MSSP participants at one-sided risk to remain in that track for a fourth year – with no rebasing of the benchmark – before transitioning to two-sided risk.

On July 7, CMS released its calendar year (CY) 2017 Medicare Physician Fee Schedule (MPFS) proposed rule delineating wide-ranging Medicare Part B policies that would take effect on Jan. 1, 2017. The proposed rule also would expand the Medicare Diabetes Prevention Program Model, require transparency of certain Medicare Advantage (MA) data, continue the implementation of appropriate use criteria for advanced diagnostic imaging services, and make selected refinements to the Medicare Shared Savings Program, among other policies.

On Aug. 25, CMS released the 2015 performance year (PY) results on MSSP and Pioneer ACOs’ financial and quality performance.

On Oct. 25, CMS said it will reopen the application period for the Next Generation ACO model for the 2018 performance year, allowing more providers to participate in the model, which qualifies as a MACRA Advanced APM.

On Nov. 2, CMS released its CY 2017 Medicare Physician Fee Schedule (MPFS) final rule delineating wide-ranging Medicare Part B payment policies. CMS finalized a fee schedule conversion factor of 35.89 for physicians participating in Medicare Part B. CMS further notes that the policies contained in the rule would improve how Medicare pays for services for patients with multiple chronic conditions and mental and behavioral health issues.

On Dec. 20 CMS announced a new Innovation Center model, the Medicare ACO Track 1+ Model, beginning in 2018, that will test a payment design that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program.

2017

On Jan. 18, CMS announced over 359,000 clinicians are confirmed to participate in four of CMS’ APMs in 2017: The Medicare Shared Savings Program (Shared Savings Program), Next Generation ACO Model, Comprehensive ESRD Care Model (CEC) and Comprehensive Primary CarePlus (CPC+) Model.

2018

In Dec. 2018, CMS  released a final rule (press release; fact sheet; blog post) affecting  ACOs participating in the MSSP by offering only two tracks, BASIC and ENHANCED, for participating ACOs. The redesigned program, called “Pathways to Success,” encourages a transition to two-sided models and significantly limits opportunities for ACOs to continue in one-sided models.