Medicare Accountable Care
Organizations may add emphasis on primary care services
Shared Savings Program Proposed Rule
reflects focus on primary care and improved incentives for
participation, quality, and efficiency
2, 2014 – In response to suggestions from program participants, experts,
consumer groups, and the stakeholder community at large, the Centers for
Medicare & Medicaid Services (CMS) has proposed changes to improve the
Shared Savings Program for Accountable Care Organizations (ACOs). CMS
says this will put “greater emphasis on primary care services and
promoting transitions to performance-based risk arrangements.”
A CM news release says it “is
seeking to continue this important dialogue to ensure that the Medicare
Shared Savings Program ACOs are successful in providing seniors and
people with disabilities with better care at lower costs.”
CMS Administrator Marilyn Tavenner
said, “This proposed rule is part of our continued commitment to
rewarding value and care coordination – rather than volume and care
duplication. We look forward to partnering with providers and
stakeholders to continuously refine and improve the Medicare Shared
Through the Affordable Care Act,
ACOs encourage doctors, hospitals and other health care providers to
work together to better coordinate care when people are sick and keep
people healthy, which helps to reduce growth in health care costs and
improve outcomes. ACOs become eligible to share savings with Medicare
when they deliver that care more efficiently while meeting or exceeding
performance benchmarks for quality of care.
Editor’s Note: There are over 360
Accountable Care Organizations working with Medicare to provide
higher-quality coordinated care for seniors. Doctors, hospitals and health care
providers establish ACOs to work together to provide better health care, while working to
slow the growth of health care cost.
By Jessie Gruman,
President, Center for Advancing Health
The Shared Savings Program now
includes more than 330 ACOs in 47 states, providing care to more than
4.9 million beneficiaries in Medicare fee for service. Recently, CMS
announced first year Shared Savings Program (SSP) results:
● 58 SSP ACOs held spending
below their benchmarks by a total of $705 million and earned shared
savings payments of more than $315 million.
● Another 60 ACOs had
expenditures below their benchmark, but not by a sufficient amount to
earn shared savings.
Other Affordable Care Act initiatives to improve care and reduce
costs have helped reduce hospital readmissions in Medicare by nearly 10
percent between 2007 and 2013 – translating into 150,000 fewer
readmissions – and quality improvements have resulted in saving 15,000
lives and $4 billion in health spending during 2011 and 2012.
CMS is seeking comment on a number
of adjustments to improve the Medicare Shared Savings Program,
● Providing more flexibility for ACOs seeking to renew their
participation in the Program. Many ACOs elect to enter the Program
under a one-sided risk model, where the organization participates in
shared savings with the Medicare program, but does not take on
additional performance-based risk. More experienced ACOs that are ready
to share in financial losses in return for the opportunity for a higher
share of savings may elect to enter a two-sided model. CMS is proposing
to give ACOs the option of a longer lead time to transition to a
two-sided performance risk model after their first agreement period.
ACOs would have the opportunity to renew under the one-sided model for
one additional agreement period. ACOs that enter the Shared Savings
Program under the two-sided performance risk model would see no change.
● Encouraging ACOs to take on
greater performance-based risk and reward. CMS is proposing to
create a new two-sided risk model, called “track 3,” which integrates
some elements from the Pioneer ACO model, such as higher rates of shared
savings and prospective attribution of beneficiaries - a list of
assigned beneficiaries provided at the start of the performance year,
and no further beneficiaries will be added to the list during the
We are seeking comments on a number
of care coordination tools that would make two-sided performance risk
models more attractive to ACOs such as expanded use of telehealth,
beneficiary attestation, and more flexibility around post-acute care
referrals to help ACOs better coordinate care for beneficiaries using
these services. These tools could all help encourage participating
providers to improve quality and care coordination for Medicare
beneficiaries, which in turn would result in better patient experiences
and greater shared savings for both the ACO and the Medicare program.
● Emphasis on primary care.
CMS proposes to refine the way Medicare beneficiaries are assigned to an
ACO to place greater emphasis on primary care services delivered by
nurse practitioners, physician assistants and clinical nurse specialists
and to allow certain specialists not associated with primary care to
participate in multiple ACOs.
● Alternative methodologies
for benchmarks. CMS seeks comment on alternative methodologies that
would make ACO benchmarks for determining shared savings and losses
gradually more independent of the ACO’s past performance and more
dependent on the ACO’s success in being more cost efficient relative to
its local market. For example, we are considering whether shared savings
received by an ACO should be added back to the benchmark in future
● Streamlining data sharing
and reducing administrative burden. CMS proposes to streamline the
process for ACOs to access beneficiary claims data necessary for health
care operations such as quality improvement activities and care
coordination while retaining the opportunity for beneficiaries to
decline to have their claims data shared with the ACO.
fact sheet with more information about the proposed rule.
The proposed rule will be open to a 60-day comment period. The
proposed rule is available for viewing in pdf format.
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