CMS Leaders Announce Major New Strategies Around ACOs

This week, a group of senior officials from the Centers for Medicare and Medicaid Services (CMS), some from the Center for Medicare, some from the Center for Medicare & Medicaid Innovation (CMMI, also called The Innovation Center) wrote an editorial. in the Perspectives section of The New England Journal of Medicine online, in which they outline their strategies for expanding and strengthening the Medicare Shared Savings Program (MSSP) in the future. In “Expanding Accountable Care’s Reach Among Medicare Beneficiaries,” published Wednesday, April 27, Douglas Jacobs, MD, MPH, Purva Rawal, Ph.D., Liz Fowler, JD, Ph.D., and Meena Seshamani, MD, Ph. D., expose their evolutionary strategies. Fowler and Rawal are officials of the Center for Innovation, while Jacobs and Sehamani are officials of the Center for Medicare. Their editorial amounts to a formal statement of strategy around developing an Accountable Care Organization (ACO) within Medicare.

The authors write that “The Innovation Center tested several ACO models, of which the ACO investment models and ACO Pioneer achieved net savings; others, including the prepayment ACO model and the next-generation ACO model, did not. The Pioneer ACO program, which enabled providers with experience coordinating patient care to move more quickly from a shared savings payment model to a population-based payment model, was associated with significant reductions emergency department visits and hospitalizations. The ACO investment model provided upfront payments to participating organizations to make infrastructure investments to improve care; these payments could be recovered by CMS through shared savings earned.

They note that “the ACO investment model has resulted in more providers from rural and underserved communities registering to participate in ACOs,” resulting in better coordination of care and reduced utilization. They state, “The ACO investment model generated $381.5 million in net Medicare savings between 2016 and 2018. The Innovation Center is currently testing the global and professional direct contract model, which has been redesigned in as the ACO Realizing Equity, Access, and Community Health (ACO REACH Model). This model will examine the effects of new risk-sharing arrangements in traditional health insurance, additional flexibility for beneficiaries (such as the ability to receive home care management), provisions to advance health equity services and reduced administrative burdens for providers on the quality of care. and Medicare costs.

Nonetheless, although officials and participants learned “important lessons about delivery and payment reform,” the authors write that “[I]Inadequate alignment between responsible care efforts, limitations of payment approaches, and lack of focus on health equity have resulted in several challenges. For example, providers were able to selectively participate in programs that produce the most favorable financial outcomes, rather than those that offer the greatest opportunity to transform care. Participation in the shared savings program has plateaued and savings for ACOs and Medicare have been limited, in part because of benchmark methodologies used to calculate savings eligibility,” they acknowledge, noting that “‘Rebasing’ – the process by which benchmarks are recalculated during contract renewals based on expenditures observed during the previous agreement period – can create a ‘ratchet’ effect, whereby ACOs that reduce their spending are then subject to a lower benchmark, undermining their chances of saving money in the future. They also recognize that the way benchmarks have been calibrated may discourage providers of care for disadvantaged populations.

Given these and other elements, CMS officials essentially acknowledge that it is time for a strategic shift, writing that “Ensuring high-quality, accountable care for all traditional Medicare beneficiaries of to 2030 will require strategic alignment between CMS ACO efforts. We are considering several changes to the Shared Savings Program and new models to expand participation in ACOs, increase savings for participants and Medicare, and make access to ACOs more equitable.

Public servants share three key areas of interest. “First,” they write, “we plan to use the Shared Savings Program as a framework for care growth and transformation by synchronizing key ACO features. This approach will provide opportunities to transform care and avoid selection based on financial methods. The Innovation Center will align testing of new ACO models and features with the shared savings program and keep certain aspects, such as financial metrics, constant. Other program requirements may be waived to assess the effects of these changes on ACO participation, savings, and equity. This approach,” they write, “could include testing modifications to existing Shared Savings Program functionality and implementing autonomous ACO-based payment and service delivery models. Successful testing could inform decisions related to improving quality, reducing inequality, increasing savings, and expanding the shared savings program, giving innovations greater reach.

Then, “Second, CMS is committed to supporting organizations that are new to value-based care and to increasing the participation of smaller ACOs that lack performance-based risk experience, infrastructure and support. limited capital and may need more time than large organizations to move. at bilateral risk. As part of efforts to expand access to the shared savings program in underserved areas, CMS is considering to adopt lessons from the ACO investment model to help provide the initial investments needed for organizations to successfully participate We are also looking at benchmarking approaches that could support increased participation, including among organizations serving patients whose care is expensive These efforts could include consideration of the effects of baseline change and baseline adjustments. this regional; for example, the Medicare Payment Advisory Commission has discussed the possibility of using benchmarks established by the administration. The Shared Savings Program has generated consistent cost savings for Medicare, including approximately $6 billion for the trust fund over the past 5 years,3 and has been associated with improvements on some patient experience measures. patients4 and perform better than physician groups in the Merit-Based Incentive Payment System, as shown above. Boosting participation would increase opportunities for beneficiaries and providers to benefit from responsible care arrangements,” they note.

And, “Third, we focus on promoting health equity by expanding the reach of COAs in underserved communities. CCOs can advance health equity by directing resources to patient needs,5 which cannot be done under Medicare’s traditional fee-for-service system. CMS is examining the use of incentives to recruit providers who serve underserved populations to join ACOs, leveraging ACO peer-to-peer learning systems to spread best practices, implementing collection requirements data and quality measurement to fill gaps in outcomes, and ask providers to consider the social needs of beneficiaries in care plans.

In this regard, they write: “Starting in 2023, the ACO REACH model will test equity-enhancing features, including a benchmark adjustment designed to mitigate provider disincentives to care for underserved populations, requirements for the participating ACOs to collect the demographic and demographic information declared by the beneficiaries. social needs data and submit health equity plans; and a new benefit enhancement that aims to increase access to primary care by expanding the privileges of nurse practitioners. Successful features could be evaluated for possible incorporation into the shared savings program. »

Officials further note that “addressing social needs must be a central objective of ACOs in the future. Lessons learned from the Responsible Health Communities model, which tested the effects of identifying and meeting the health-related social needs of beneficiaries using screening, referral and community navigation services, will be considered for possible incorporation into the shared savings program. We are also exploring whether new ACO quality measures related to identifying and addressing social needs could support these initiatives.

And, they conclude that, “By better aligning CMS ACO initiatives and policies, Medicare can create pathways for payers and providers to advance responsible care.” This approach could provide a greater number of beneficiaries with an improvement in quality and patient experience, as well as the possibility of entering into a care relationship that meets medical and social needs. For providers, aligning initiatives and policies could increase participation rates and accelerate care transformation. Our goal is to send clear and consistent signals that the opportunities offered by the Shared Savings Program and Innovation Center models represent a coordinated path to support

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