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What It Means to Patients: Medicare Shared Savings Program Proposed Rule

ACOS ARE THE DRIVING FORCE IN THE MOVE TO VALUE-BASED CARE
Medicare’s ACO program is the largest value-based payment model in the country and an essential tool in moving the health system toward better value by incentivizing more efficient, higher quality, lower cost care. More than 560 ACOs participate in the Medicare Shared Savings Program (MSSP), serving 10.5 million seniors, making ACOs the fastest growing Medicare program in its more than 50-year history. 

ACOS OFFER BETTER QUALITY AND OUTCOMES
Several independent evaluations and CMS data show ACOs are helping improve the quality of care Medicare patients receive. In 2016, 99 percent of the 438 Track 1 ACOs met quality standards, according to the Medicare Payment Advisory Commission. ACOs produced lower hospital readmission rates 90 percent of the time compared to fee-for-service providers outside of ACOs, according to the Department of Health and Human Services Inspector General. ACOs with at least four years of experience improved their average quality performance by 15 percent between 2013 and 2016, CMS said in its recent proposed rule. Even in ACOs with older, sicker patients, quality was still improved.

ACOS FOCUS ON ‘PATIENT-CENTEREDNESS’ AND PATIENT CHOICE
ACOs must meet criteria for “patient-centeredness” including developing patient care plans, identifying high-risk patients and establishing care coordination activities. As a result, patient-experience surveys, which ACOs are mandated to administer annually, have proven to meaningfully improve care, research has shown. Further, CMS requires ACOs to engage beneficiaries in their leadership to ensure a patient voice is included in each ACO’s leadership. ACOs also allow seniors to maintain their choice of provider. MSSP is the only formal Medicare program outside of Medicare Advantage (MA), where the providers are organized to coordinate across the whole continuum of care. Limiting the number of ACOs would leave MA as the only option to have access to these important services. Many seniors do not want the network restrictions that typically come with MA.

NEW CMS ‘PATHWAYS TO SUCCESS’ PROGRAM
On August 9, CMS released a proposed rule titled “Pathways to Success,” containing significant proposed changes to MSSP. 

What’s Good:

  • Offers Seniors Incentives to get the right care: A proposed new beneficiary incentive program would allow certain ACOs to pay seniors up to $20 for qualifying visits.
  • Removes Telehealth Restrictions: CMS wants to allow certain ACOs to offer telehealth services in patient homes, expanding patient choice and access to care.
  • Expands use of the Skilled Nursing Facility (SNF) waiver: CMS would expand the use of a popular waiver that allows beneficiaries to more easily access SNF care without having a hospital stay first. 

‘PATHWAYS’ COULD JEOPARDIZE ACO GROWTH AND FREEDOM OF PATIENT CHOICE
Medicare officials want to force new ACOs into risk-bearing models after two years, despite evidence that ACOs need more time to produce positive financial results. Combined with a cutting of shared savings payments from 50 percent to as low as 25 percent, NAACOS expects the pipeline of new ACOs to run dry if these policies are finalized. Fewer providers moving to value-based care models risks losing the momentum built in recent years in the shift away from siloed, uncoordinated care. 

WHAT IS NAACOS SEEKING?

  • ACOs need more time before being required to accept risk for holding down spending.
  • CMS should at least maintain the current 50 percent shared-savings rate for ACOs in shared savings-only or low risk models.