25 Things to Know About The CMS Medicare ACO Proposed Rule: Pathways to Success

By Clive Riddle, August 10, 2018

Here are 25 major points to note in the CMS Pathways to Success Proposed Rule introduced on August 9th:

1. The redesigned Medicare Shared Savings program is called “Pathways to Success.
2. There are five stated goals Pathways to Success is intended to advance: Accountability, Competition, Engagement, Integrity, and Quality.
3. The CMS projected financial impact of the proposal would be savings to Medicare of $2.2 billion over ten years.
4. CMS notes that 460 of the 561 or 82% of all ACOs in the Shared Savings Program in 2018 – are not taking on risk for increases in costs.
5. The amount of time that an ACO can remain in the program with upside-only risk  would be limited to two years (or one year for ACOs identified as having previously participated in MSSP under upside-only risk) instead of the current timetable of up to six years.
6. A 6-month extension would be provided for current ACOs whose agreements expire at the end of 2018, along with a special one-time July 1, 2019 start date that will have a spring 2019 application period for the new participation options.
7. The number of tracks would be reduced to two, the “BASIC” track and the “ENHANCED” track, and would allow providers to pick between these two tracks. 
8. The length of ACO participation agreements would expand from three years to five years.
9. The BASIC track would feature a glide path for taking risk.  It would begin with up to two years of upside-only risk and then gradually transition in years three, four, and five to increasing levels of performance risk, concluding in year five at a level of risk that meets the standard to qualify as an Advanced Alternative Payment Model (APM) under MACRA. 
10. Current upside-only ACOs would be limited to one year without risk before being required to transition to the risk level in year three of the glide path.
11. The ENHANCED track would allow providers to take on risk and qualify as an Advanced APM immediately.  This track would offer the same amount of risk for each of the five years of the agreement period, at a level of risk sharing higher than the maximum amount reached in the BASIC track.
12. Eligible ACOs (ACOs that are inexperienced with two-sided risk in Medicare) would be able to enter at any level of risk in the BASIC track’s glide path or go straight to the ENHANCED track.
13. After completing a five-year agreement under the BASIC track, low revenue ACOs would be able to renew for a second agreement period at the highest level of risk in the BASIC track, while high revenue ACOs would be required to move to the ENHANCED track and take on additional risk.
14. Each ACO would provide a standardized written notice to its Medicare beneficiaries, informing them at their first primary care visit of a performance year that they are in an ACO and what that means for their care.
15. CMS would allow certain two-sided ACOs to provide an incentive payment of up to $20 to each assigned beneficiary for each qualifying primary care service that the beneficiary receives, as an incentive for taking steps to achieve and maintain good health. 
16. CMS is seeking comment on an approach that would allow beneficiaries to opt in to an ACO as an alternative to assignment. 
17. CMS would streamline the measures that ACOs are required to report, to ensure that all measures have a meaningful impact on patient care.
18. CMS would require a specified percentage of the eligible clinicians participating in an ACO to adopt the 2015 edition of Certified EHR Technology (CEHRT) as part of the Administration’s MyHealthEData initiative promoting interoperability of medical data and patient control of their data.
19. Physicians in ACOs that take on risk could receive payment for telehealth services provided to patients regardless of the patient’s location.
20. Regional (county-level) spending would be incorporated into ACO benchmarks starting in their first agreement period.
21. Methodology for risk adjustment would more accurately account for changes in beneficiaries’ health status.
22. When calculating and updating benchmarks, CMS would factor in national spending growth rates in addition to regional rates, so ACOs that constitute a large fraction of their local market would not be penalized if they reduce the market growth rate.
23. ACOs in two-sided models would be accountable for losses even if they exit mid-way through a performance year.
24. Termination of ACOs with multiple years of poor financial performance would be authorized.
25. The detailed Medicare Shared Savings Program Notice of Proposed Rulemaking (CMS-1701-P), “Accountable Care Organizations‑‑Pathways to Success,” is available at https://www.federalregister.gov/public-inspection/  and https://www.cms.gov/newsroom/fact-sheets/proposed-pathways-success-medicare-shared-savings-program.