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October 3, 2016
Mr. Andrew Slavitt
Re: (CMS-5519) Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)
Submitted on October 3, 2016 via www.regulations.gov
Dear Acting Administrator Slavitt:
The National Association of ACOs (NAACOS) appreciates the opportunity to submit comments on the proposed rule, “Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)” (file code CMS-5519), as published in the August 2, 2016 Federal Register.
NAACOS is the largest association of ACOs, representing over 3.13 million beneficiary lives through 210 Medicare Shared Savings Program (MSSP) ACOs, Next Generation, Pioneer and Commercial ACOs. NAACOS is an ACO member-led and member-owned non-profit organization that works on behalf of ACOs across the nation to improve the quality of Medicare delivery, population health and outcomes, and health care cost efficiency. Our members, more than many other healthcare organizations, want to see an effective, coordinated patient-centric care process. Our recommendations reflect our expectation and desire to see ACOs achieve the long-term sustainability necessary to enhance care coordination for Medicare beneficiaries, reduce healthcare costs, and improve quality in the Medicare program.
Summary of Key Recommendations
Specifically, in the final EPM rule, NAACOS urges CMS to:
Timeline and Authority for the Proposed Expansion of Episode and Bundled Payment Models
CMS proposal: CMS proposes to expand the current CJR model, create a new Cardiac Episode Payment Model (EPM) and establish a Cardiac Rehabilitation Incentive Payment Model. The agency also discusses making future plans to implement a new voluntary bundled payment model building on the Bundled Payments for Care Improvement Initiative (BPCI).
Additional comments: CMS’s rapid expansion of bundled and episode payment models has the potential to disrupt and compromise the success of other CMS initiatives, such as the MSSP and other ACO models. CMS EPM initiatives have just begun, with the CJR model starting only several months prior to the release of this proposed rule. It is irresponsible of CMS to launch a broad expansion of the CJR experiment before any results have been evaluated. The effects of the overlap of a multitude of programs being released by CMS and the Centers for Medicare & Medicaid Innovation (CMMI) is yet to be seen and could have devastating consequences for the success of ACOs. ACOs focus on total cost of care and population health, while episode and bundled payments focus on a specific disease state while ignoring the important issues of avoiding unnecessary services, utilization/volume of services and prevention.
We urge CMS to pause to reevaluate the results of the CJR experiment and determine the impact of the current overlap policies for that model prior to finalizing any expansion of CJR or creating additional bundled and/or episode payment models. As detailed in our recent letter to the agency on this issue, CMS policy should promote the growth of population-based payment models that take responsibility for the entirety of patients’ care needs and invest in care coordination throughout the year, thus reducing costly care such as avoidable hospitalizations.
Further, we question if CMS has the authority under ACA Section 3021 to mandate EPM bundles as proposed. CMS does not have the authority to implement a demonstration that harms a permanent Medicare program such as the MSSP, which this proposal would do. We are very concerned about the negative impact of this proposed rule on ACOs and recommend CMS reconsider the use of mandatory demonstrations.
General Approach to Addressing ACO Overlap with Episode Payment Models
CMS Proposal: For the new EPMs, CMS proposes to follow the same general policy the agency uses for CJR when there is overlap with the new bundled payments and ACOs. Specifically, as with CJR, CMS proposes to attribute savings achieved during an EPM episode to the EPM participant. However, CMS proposes to test an alternative strategy to address ACO overlap by excluding beneficiaries from EPMs who are aligned to ACOs in the Next Generation ACO model and ESRD ESCOs in the Comprehensive ESRD Care initiative in tracks with downside risk for financial losses. Additionally, CMS seeks comment on, but does not propose, excluding beneficiaries from EPMs that are prospectively assigned to MSSP Track 3 ACOs or other two-sided ACO risk models.
Additional comments: We appreciate CMS’s proposal to exclude beneficiaries from EPMs when they are aligned to ACOs in the Next Generation model and ESRD ESCOs in the Comprehensive ESRD Care initiative in tracks with downside risk for financial losses. We request that CMS finalize the exclusion of these beneficiaries, but we strongly urge CMS to expand this proposal by excluding all ACO assigned beneficiaries from the newly proposed EPMs and from CJR bundles unless a collaborative agreement is in place between a hospital EPM participant that is not also a participant of a particular ACO. Unless a collaborative agreement is in place, CMS should exclude ACO beneficiaries who are assigned using either prospective or retrospective assignment. Regarding the latter, CMS should remove any beneficiaries who are identified on preliminary assignment lists as well as those identified on quarterly preliminary prospective assignment lists provided to ACOs throughout the performance year. Overall, the exclusion of beneficiaries should not be limited to those in select ACO models, which only comprise a small fraction of Medicare ACOs. Collaborative agreements between ACOs and bundlers would encourage integration and cooperation and would allow ACOs and bundlers to leverage existing resources versus duplicating them.
We also recommend that when the EPM hospital is a participant in an ACO, CMS should permit the ACO participant to have the option to remove themselves from the EPM program, be it CJR or one of the newly proposed EPMs. This would allow them the opportunity to devote their limited resources to the efforts of their ACO which focuses on care throughout the year, including the episodes that would otherwise be included in the bundled payment programs.
CMS’s current approach to addressing the overlap between ACOs and episode and bundled payment models severely undermines ACOs. CMS has repeatedly maintained that as the agency develops new payment models and initiatives, they do not want to harm existing programs. Unfortunately, the EPM and CJR proposals would negatively affect ACOs and threaten their viability. NAACOS supports the coexistence of delivery system reform payment models and programs, however the presence of one program cannot be to the direct detriment of another model. The proposed CJR expansion and cardiac EPMs continue the trend of a growing number of competing value-based payment models existing within the same markets. This presents significant challenges to CMS, stakeholders and patients. In the Regulatory Impact Analysis on page 50995, CMS states, “Additionally, we were unable to fully estimate the impact of the proposal in section III.D. which addresses beneficiaries in EPMs who are also aligned or attributed to a Medicare Shared Savings Program participant or a participant in an ACO model initiated by the CMS Innovation Center.” This admission is deeply troubling and reason alone to err on the side of caution and wait to implement new bundled payments until this overlap can be rigorously evaluated and addressed. We also urge CMS to release the necessary data to allow independent researchers to study this issue.
We urge CMS to take immediate action to give priority to population-based models and exclude ACO beneficiaries from bundled payment programs unless a collaborative agreement exists between the bundler and the ACO. CMS argues that prioritizing bundled payment programs helps assure adequate sample size for bundlers. However, much of the variation in per-episode spending is a result of utilization of post-acute care or readmissions, both of which ACOs are often instrumental in managing or preventing. Per episode spending is also often driven by variability of comorbid or exacerbating social factors, challenges we urge CMS to address. ACOs focus on, and make considerable investments in, care coordination and improving care transitions to manage post-acute care effectively. Many successful ACOs credit these efforts for allowing them to achieve shared savings.
While bundled payments may be able to deliver savings over the short term, often as a result of case selection, placing an emphasis on these programs which do not address volume or total cost of care undermines the success of ACOs in the long term and threatens to increase Medicare costs overall. Episode payment programs focus on a traditional and outdated payment method by paying regular fees as well as any savings beyond the discount, an approach which may incentivize providers to increase volume. Further, some bundled payment participants may select healthier patients and could avoid sick patients, resulting in the appearance of improved performance as well as higher profits for the participant. For example, there are many cases of a lowering of HbA1c thresholds without a program from the bundler to address blood sugar levels of the newly excluded patients.
A recent study, Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes, published in the Journal of the American Medical Association (JAMA) on September 19, 2016 examines hospitals in BPCI and their quality results and expenditures. The study compared changes in spending, utilization, and quality for Medicare beneficiaries who underwent lower extremity joint replacement during a baseline period before the BPCI initiative was launched (October 2011 through September 2012) and the early intervention period (October 2013 through June 2015). While there was no meaningful difference with quality results (claims-based quality measures were nearly identical at baseline in BPCI and control hospitals and changed in similar ways during the intervention period), the study did find statistically significant results for spending and utilization.
A major finding of the study was that while spending decreased in both the intervention and control populations, the spending decrease for lower extremity joint replacements was significantly greater for health care organizations in BPCI. However, when evaluating bundled payments, it is critical to not just focus on spending changes for the bundled payment episode but to also examine any potential changes in overall volume of these episodes. Further analysis that takes into account the total volume of bundles showed that total spending actually declined lessin the BPCI hospitals than in the comparison hospitals.
In a JAMA editorial by Elliot Fisher in response to this study, Fisher notes,
“A third concern is whether the design of the evaluation was sufficiently sensitive to behavioral changes that could make any apparent savings misleading. One of the questions surrounding bundled payments is whether the effort to align financial incentives between physicians and hospitals could contribute to increases in volume or shifts in case mix toward healthier (more profitable) patients. The authors’ choice of the primary end point, per-episode payments, is one issue. They provide data showing that the volume of procedures in the BPCI hospitals increased from a mean of 61.5 lower extremity joint replacement discharges per quarter per hospital in the baseline period to 64.6 during the intervention period, while volume decreased in the comparison group, from 59.6 to 59.2 lower extremity joint replacement discharges per quarter per hospital… the assumption that bundles will save CMS money because of the mandatory discount will only be true if there are not behavioral responses that lead to increased volume or the substitution of healthier patients for sicker patients (who may have the most to gain).”
Many ACOs successfully manage acute care and post-acute care expenditures below regional or national mean costs, and the current bundled payment overlap policies deprive them of a key source of savings. CMS acknowledges the success of these ACOs and on page 50870 states,
“We are aware of situations in certain markets that seem to reduce opportunities for ACOs to achieve savings given historic experience that indicates these particular ACOs are able to manage the care within episodes as successfully as EPM participants. Attributing savings to participants in episode payment models, such as CJR participants and EPM participants under this proposed rule, creates a problem where the ACO is accountable for coordinating a beneficiary’s care over a performance year but is not able to benefit from savings achieved from episodes completed during the performance year. Data shows that post-acute care spending is among the most significant sources of savings for ACOs currently, and where they focus significant investments.”
Under current and proposed policies, bundled payment participants often have little or no incentive to collaborate with ACOs, a situation which threatens the continuity of care for patients. Bundled payment participants have a greater incentive to free-ride off an ACO’s efforts to coordinate care over the course of the full year which includes the episode. As discussed later in this letter, we applaud CMS’s proposal to allow ACOs to be formal “collaborators”. We hope this policy change will encourage more collaboration between unrelated bundlers and ACOs, and we urge the agency to require collaborative agreements between bundlers and unrelated ACOs in the same market or have the bundlers face the exclusion of all ACO assigned beneficiaries. Should this occur, we urge CMS to remove all ACO beneficiaries who are assigned using either prospective or retrospective assignment. Regarding the latter, CMS should specifically remove any beneficiaries who are identified on preliminary assignment lists as well as those identified on quarterly preliminary prospective assignment lists provided to ACOs throughout the performance year. This requirement would ensure an optimal outcome by bringing both parties to the table to work together to collaboratively design care coordination processes and enhance beneficiary outcomes. Further, it would incentivize hospitals to determine the best way to provide information on beneficiary admissions to primary care providers, thus involving primary care providers as early as possible to manage care and prevent adverse events and costly readmissions.
CMS cites the lack of prospective patient attribution as a potential administrative issue preventing them from excluding ACO assigned beneficiaries from bundles. Specifically, CMS explains in the proposed rule that prospective assignment would be operationally necessary in order to adopt an overlap policy that would exclude ACO patients from bundles/EPMs. Therefore, we urge CMS to CMS provide all ACOs with the opportunity to elect prospective assignment regardless of their model or MSSP track. We have repeatedly requested this flexibility from CMS for a variety of reasons such as stable beneficiary populations and targeted care redesign efforts, and we reiterate this request in light of CMS’s comments in the proposed EPM rule. However, we also question the claims that prospective alignment would be absolutely necessary in order to exclude ACO beneficiaries from bundled payment programs when a collaborative agreement is not in place. CMS could exclude these beneficiaries by providing hospital bundled payment participants with lists of patients prospectively assigned to Medicare ACOs in their MSA as well as beneficiaries identified on quarterly preliminary prospective assignment lists provided to ACOs throughout the performance year.
Or, CMS could provide access to a CMS-maintained database of prospectively or tentatively assigned MSSP beneficiaries.
We also question CMS’s rationale for the proposed overlap policy and urge the agency to carefully consider the long-term ramifications this would have. On page 50869, CMS explains,
“Several strong considerations drive us to otherwise follow CJR precedent for addressing ACO overlap. First, CMS continues to avoid double payment of savings and double recoupment of losses, which is an important principle of successful payment reform. Second, in implementing the EPMs, there would be no additional operational effort due to consistency in ACO overlap policies across models. In this respect, we anticipate little to no difficulty in replicating prior policy as new episode payment models are introduced. Third, this would have no negative financial impact on EPM participants, an important consideration for future EPMs.”
We are very disappointed that CMS is prioritizing the operational ease of expanding an existing flawed policy rather than finding the best policy to benefit Medicare patients, providers and the Medicare Trust Fund. While CMS cites “no negative financial impact on EPM participants,” there is no mention of the negative financial impact on ACOs. CMS must not consider these programs in isolation but must look across all Medicare value-based initiatives which interact and overlap with one another.
On page 50869, CMS states, “We do not believe that testing a new approach to addressing overlap, which could potentially disrupt ACO investments, operations, and care redesign activities, would be appropriate at this time prior to a test with a smaller population. We plan to monitor and learn from the test of excluding beneficiaries prospectively assigned to an ACO from risk tracks and consider these results and comments in future rule-making.” While CMS is reluctant to test a new approach across ACOs, the agency does not have any reluctance to testing mandatory bundled payments on a large scale. The new EPM rule would require mandatory participation in 98 MSAs, which is in addition to the significant participation already required for CJR in 67 MSAs. We urge the agency to significantly slow down implementation of mandatory bundles. Should the agency move forward with such a large scale rollout of the new EPMs and expanded CJR, we urge CMS to move just as quickly to protect ACOs from the unintended negative consequences of this program overlap before it’s too late. Not doing so would certainly disrupt ACO investments, operations and care design activities.
Finally, on page 50868 CMS states its desire to “preserve the integrity of ongoing model tests without introducing major modifications that could make evaluation of existing models more challenging.” The overlap of bundled payment programs and population-based programs such as ACOs certainly compromises the integrity of ongoing programs as well as limits the ability to properly evaluate the effect of each program. The overlap of these models makes it very difficult to evaluate their separate outcomes, which will become increasingly important as CMS considers which models to expand and focus on in the future.
Financial Reconciliation Methodology when ACOs and EPMs Overlap
CMS Proposal: As explained above, CMS would exclude beneficiaries from EPMs who are aligned to Next Generation ACOs and ESRD ESCOs in the Comprehensive ESRD Care initiative in tracks with downside risk for financial losses. For all other ACO models/tracks, CMS proposes to attribute savings achieved during an episode to the EPM participant and include EPM reconciliation payments for MSSP ACO-aligned beneficiaries as ACO expenditures.
CMS proposes that under EPMs, they would make an adjustment to the reconciliation amount to account for any of the applicable discount for an episode resulting in Medicare savings that is paid back through shared savings under the MSSP or any other ACO model when an EPM hospital also participates in the ACO and the beneficiary in the EPM episode is also aligned to that ACO. This policy allows CMS to reclaim from the EPM participant any discount percentage paid out as shared savings for ACOs when the hospital is an ACO participant and the beneficiary is aligned with that ACO. CMS would not adjust reconciliation payments for EPM participants when a beneficiary receives an AMI, SHFFT or CABG at a hospital participating in the corresponding EPM and that beneficiary is aligned to an ACO in which the hospital is not participating.
Additional comments: We strongly oppose certain elements of CMS’s proposal to address financial reconciliation of EPMs and ACOs when overlap occurs. On page 50867, CMS notes “a payment reconciliation policy is necessary in order to credit the entity that is closest to that care for the episode of care in terms of time, location, and care management responsibility.” However, CMS’s proposal does not necessarily prioritize the proper entity as the agency’s proposal always gives precedent to the bundled payment participant. As explained previously, we recommend that when an EPM hospital is a participant in an ACO, CMS should permit that ACO participant to have the option to exclude themselves from the EPM program, be it CJR or one of the newly proposed EPMs. This would allow them the opportunity to devote their limited resources to the efforts of the ACO which focuses on care throughout the year, including the episodes that would otherwise be included in the bundled payment programs. Should CMS not address overlap by removing ACO assigned beneficiaries unless a collaborative agreement is in place, we strongly recommend that the agency continue not to reduce ACO reconciliation payments when a beneficiary receives an AMI, SHFFT or CABG at a hospital participating in the corresponding EPM and that beneficiary is aligned to an ACO in which the hospital is not participating.
We strongly object to CMS’s proposal to include EPM reconciliation payments for MSSP ACO-aligned beneficiaries as ACO expenditures when the ACO does not include an EPM hospital participant. This approach favors EPM participants at the direct expense of ACOs by prioritizing the EPM participant who takes precedence with savings and then including the EPM’s reconciliation payments as ACO expenditures. This arbitrarily and unfairly inflates ACO benchmarks and can mean the difference between an ACO surpassing their Minimum Savings Rate (MSR) in order to be eligible for shared savings. It also undermines ACOs’ opportunity for savings through care redesign since any savings would automatically go to the bundler. Further, CMS recently changed this policy for 2016 as it pertains to the overlap of Next Generation and Pioneer ACOs with BPCI. A CMS FAQ on this change states:
“Reminder! Methodology Change: Pioneer and NGACO-- BPCI Non-Claims Based Payment & ACO Expenditures
Effective for the 2016 performance period, CMS will make a change to how non-claims based payment expenditures for the Bundled Payments for Care Improvement (BPCI) initiative are included in Pioneer and NGACO expenditures at settlement. This change introduces a new conditionality upon which the BPCI reconciliation amounts will not be included in total Parts A and B expenditures for aligned beneficiaries. BPCI reconciliation amounts will not be included as Parts A and B expenditures when they would cause the Pioneer or NGACO to a) incur shared losses (when the ACO would not have otherwise owed losses) or b) prevent the receipt of shared savings (when the ACO would otherwise have received savings). In all other scenarios, the BPCI expenditures will be reconciled per current policy. The amendments to the Participation Agreements are being finalized and will be made available for review as soon as possible.”
This policy change for 2016 illustrates that the agency recognizes the effect these reconciliation payments have on ACO benchmarks. Unfortunately, the solution for the 2016 performance year doesn’t go far enough but it is at least better than CMS’s proposal which does not exclude EPM reconciliation payments from ACO expenditures. CMS explains that their desire to avoid double paying bonuses is a key reason for their financial reconciliation overlap policy. However, by adopting the proposed overlap policy, CMS would overpay for certain services provided by bundle participants while also losing potential savings that could have been derived through less intensive or expensive treatment provided by an ACO.
While certain ACOs can benefit from bundled payment program overlap if a bundle target price is lower than the ACO’s actual spending, this policy skews accountability and is not an optimal policy or financial solution for Medicare.
The agency’s rationale is that this adjustment would be necessary to ensure that the applicable discount under the EPM is not reduced because a portion of that discount is paid out in shared savings to the ACO and thus, indirectly, back to the hospital. However, it is important to note that ACOs only receive shared savings if they surpass their MSR, thus ensuring that they are already saving Medicare money and that savings is also spilt with the government. We urge CMS to finalize a policy which excludes EPM reconciliation payments from ACO expenditures. The simple and clear solution is to remove ACO assigned beneficiaries from bundled payment programs unless a collaborative agreement exists between a hospital EPM participant that is not also a participant of a particular ACO. By not doing so, CMS creates the need to develop complex and flawed policies to address the entanglement of the overlapping programs.
CMS Proposal: CMS proposes to make ACOs eligible to become EPM collaborators, and, therefore, to receive gainsharing payments, provided that they meet stated quality of care criteria and have providers that render items and services to EPM beneficiaries during EPM episodes. Unlike other EPM collaborators, whose alignment payments cannot exceed 25 percent of the repayment amount of the EPM participant with which they are aligned, CMS proposes to allow ACOs to contribute up to 50 percent of such repayment amounts. CMS also proposes that all EPM participants must develop written policies for selecting EPM collaborators. Finally, CMS proposes that EPM participants not take into account "the amount of EPM activities provided by a potential or actual EPM collaborator relative to other potential or actual EPM collaborators," fearing that this would introduce the risk that a financial arrangement could be based on the volume or value of referrals. CMS proposes allowing ACOs to participate as collaborators in both the new EPM and CJR models, which would revise existing regulations governing CJR.
Additional Comments: We have repeatedly advocated for CMS to allow ACOs to participate as formal collaborators and are very pleased with CMS’s proposal to modify CJR and implement an EPM policy allowing ACOs to participate as formal collaborators. We urge CMS to finalize this proposal with slight modifications to the specific details about ACO collaborators. CMS's efforts to engage ACOs as EPM collaborators will permit ACOs to use their substantial expertise and resources to contribute to the EPM's dual goals of limiting spending and increasing quality. We believe that these decisions would appropriately recognize the expertise that ACOs offer EPM participants with regard to managing the cost and quality of care that Medicare beneficiaries receive.
We do not support CMS's proposal to permit ACOs to contribute up to 50 percent of an EPM participant's repayment amount, while limiting the potential repayment amount to 25 percent for other collaborators. While we appreciate CMS’s recognition of the valuable role ACOs can play, it is inappropriate for CMS to interfere in the negotiations between an EPM participant and its collaborators. These negotiations should permit both parties to jointly agree on the terms and conditions of the arrangement, including specifics around gainsharing or repayment percentages. It is unnecessary and an overreach of government to place limits on either the gainsharing or repayment amounts as long as they do not collectively exceed the amount the EPM participant would receive from CMS or have to repay. We request that CMS not finalize any particular cap on either gainsharing or alignment payments. We recommend CMS also revise the CJR policy specifying alignment payment caps and let the market determine the best arrangements for the parties involved.
We recommend that CMS modify its limitation on EPM participants' consideration of "the amount of EPM activities provided by a potential or actual EPM collaborator relative to other or potential EPM collaborators" to instead limit EPM participants' consideration of the amount of such EPM activities between the parties, which would allow EPM participants to consider a potential EPM collaborator's relevant experience. We recognize and support CMS’s desire to prevent EPM participants from developing methodologies for selecting EPM collaborators that take into account the "volume or value" of past or anticipated referrals generated by, among or between the parties. However, read literally, the language included in the proposed rule indicates that the amount of activities, or experience, that a potential EPM collaborator has cannot factor into such a methodology. Not allowing EPM participants to consider a potential EPM collaborator's relevant experience would compromise the EPM's stated goal of increasing quality while reducing cost. CMS's objective can be achieved without eliminating experience as a qualifying factor by prohibiting EPM participants from considering the amount of EPM activities transacted between the parties, as opposed to all EPM activities transacted in the past, as the proposed language could be read. Finally, we recommend that CMS require that EPM participants' written policies for selecting EPM collaborators be made public to promote transparency.
Fraud and Abuse
CMS Proposal: CMS proposes to maintain the ACO fraud and abuse waivers that were introduced in 2011, and will consider whether additional fraud and abuse waivers are necessary to carry out the provisions of the EPM.
NAACOS Recommendation: NAACOS welcomes CMS's maintenance of the 2011 fraud and abuse waivers, and its commitment to ensuring that ACOs can continue to innovate and further the quality and cost-oriented objectives of the EPM.
Expansion of the Bundled Payments for Care Improvement Initiative
CMS proposal: While not formally proposed in this rule, CMS discusses building on the BPCI initiative, stating that CMMI intends to implement a new voluntary bundled payment model for 2018 where the model(s) would be designed to meet the criteria to be an Advanced APM.
Additional comments: We have concerns with CMS’s intent to build upon the BPCI program in 2018 but also think that, if structured properly to address program overlap and expand participants to include ACOs, a new voluntary bundled payment program could positively align bundled payments and population-based models. However, we reiterate our concerns outlined in this letter about the effect of the overlap of bundled payment programs, including BPCI, and ACOs and urge CMS to take this feedback into consideration before introducing a new voluntary bundled payment program. Specifically, ACO beneficiaries should be excluded from bundled payments unless a collaborative agreement exists between an ACO and a hospital that is not a participant in that ACO. We also urge CMS to use a consistent policy across bundled payment programs to address program overlap. CMS should carefully study the effect BPCI has had on other existing programs such as the MSSP before moving forward, and we are encouraged that preliminary research on BPCI is becoming available, including the study we referenced earlier in this letter.
We urge CMS to allow ACOs to be applicants for a new voluntary bundled payment program. Doing so would allow ACOs to effectively manage the bundled payment episode as well as the patient’s care throughout the year. It makes little sense to arbitrarily divide bundlers and population-based healthcare providers when in reality ACO providers should be able to be responsible for a bundle within a population-based model. Effectively managing a bundle within a performance year would reinforce the objectives of the ACO and would likely generate more savings for Medicare. We also urge CMS to re-evaluate the role of conveners with respect to bundled payment programs such as BPCI. Specifically, we have concerns that allowing private for-profit awardee conveners to absorb the risk for providers adds an unnecessary layer to our healthcare system without benefiting patients or Medicare. CMS should exclude for-profit risk-taking conveners which do not provide patient care. We do not share the same concerns about facilitator conveners who don’t take risk for the bundlers and instead serve as an aggregator to bring a group of participants under one application and help to implement consistent delivery reform efforts across the group of participants.
In an ideal world, there would be opportunities for both population-based payment models such as ACOs and bundled payment models to co-exist and even support one another. Unfortunately, as currently structured these models compete with one another, and depending on how CMS chooses to address their overlap, that competition could harm ACOs and significantly weaken their ability to succeed as a payment model. In sum, we ask CMS to refrain from implementing any new voluntary or mandatory bundled payment programs unless the overlap issues described in this letter can be resolved. ACOs are at a critical turning point, and with the implementation of MACRA accelerating the proliferation of new and innovative payment models, CMS must take action to avoid competing priorities and problems that exist when multiple programs overlap. We respectfully request CMS consider the feedback from the ACO community detailed in this letter.
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