ACO leaders also provided the latest evidence that physicians remain largely disengaged from the looming requirements of MACRA.


Sept. 29—Medicare’s leader called for more “conversations” when asked what his agency will do next to improve beneficiary engagement in accountable care organizations (ACOs).

More conversations are needed in Congress and among providers on ways to increase beneficiary engagement in ACO-type models, Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), told attendees at a Washington, D.C., meeting of physician groups engaged in ACO-types models.

Instead of aggressive moves to expand patient engagement features in ACOs, discussions are needed to focus on “how do we continue to get [patients] more engaged and then how do we demonstrate that it works,” Slavitt said.

“At the end of it all, that’s really what matters,” Slavitt said during a meeting of CAPG, the Voice of Accountable Physician Groups.

CAPG and other physician group advocates long have told CMS that adopting enhanced beneficiary engagement features is key to the future success of ACOs.

Slavitt noted that CMS has responded over the last year or so by introducing new ACO models “with beneficiary incentive baked in.”

Next Gen Improvements

For instance, the Next Generation ACO model includes “modest beneficiary incentives to engage them,” Slavitt said.

Twenty-one organizations have opted to participate in the Next Generation ACO Model in 2016, the program’s first performance year. By comparison, the older Medicare Shared Savings Program (MSSP) included 434 ACOs at the start of 2016.

Those “crucial” components of Next Generation ACOs, Slavitt said, have included giving enrollees access to services such as telehealth, offering reward payments when beneficiaries obtain care from the ACO and affiliated providers, and providing a process for beneficiaries to confirm their care relationship with ACO providers.

However, earlier and much larger ACO models have very limited ability to engage patients in care-improvement efforts because patients were not allowed to opt in based on information about the model and its value proposition, analysts have concluded. The consequence has been that ACOs have trouble effectively managing the care of their attributed patients because much of it is obtained outside of the ACO. For instance, one studyfound that two-thirds of specialty office visits for attributed beneficiaries occurred outside of the assigned ACO.

“For us, one of the challenges has been that there is complete choice in” MSSP, said Amy Frankowski, MD, chief medical officer for Mercy Health Select. “So our patients may be attributed to us, but they may seek their care anywhere in the communities where we are at or perhaps in multiple states, depending on where they travel during the Ohio winters, which is generally down south.” 

Additionally, the freedom of Medicare beneficiaries to seek services with providers of their choice can fuel ACO patient population upheaval over time. For instance, one study of a large Pioneer ACO found only about two-thirds of aligned members in a given year were aligned in the previous year.

In 2017, Next Generation ACOs will begin offering voluntary alignment, which will allow Medicare enrollees to pick their ACO instead of being assigned to one by an algorithm. That change is expected to allow the ACOs to develop a more consistent member base, according to an assessmentby Milliman.

Meanwhile, MSSP ACOs have struggled to overcome a mentality among Medicare beneficiaries that being part of an ACO would lock them in and limit choice, said Philip Oravetz, MD, director of accountable care for Ochsner Health System.

“We haven’t done a good enough job of educating patients about the value of coordinated care,” Oravetz said in an interview. “You’re not giving up choice, you are getting improved quality, you’re getting improved value. We haven’t delivered that message well.”

MACRA Efforts

Slavitt also noted that future changes CMS is considering making to the Medicare Access and CHIP Reauthorization Act (MACRA) include expanding the number and variety of advanced alternative payment models (APMs).

Additionally, the agency is trying to figure out how to open access for physician groups to join the existing qualifying APMs “as soon as possible.”

Less than 10 percent of physicians paid under Medicare Part B are expected to qualify for payment in the APM track for care provided in 2017, the first year MACRA goes into effect. The rest of Medicare Part B payments are expected to flow through the Merit-based Incentive Payment System (MIPS).

Many physicians were unlikely to focus on MACRA requirements until after the first year’s payment adjustments are assessed in 2019, according to CAPG attendees. Penalties under MIPS for physicians who fail to outperform their colleagues in measures of quality and other factors are up to 4 percent of their Medicare revenue in 2019 (based on performance year 2017) and up to 9 percent in 2022 (based on performance year 2020).

“After the first year of cuts, most physicians will look to take action,” Kurt Ransohoff, MD, CEO and chief medical officer of Sansum Clinic, said at CAPG.

Specifically, older physicians have indicated they are more likely to absorb MACRA cuts until their retirement, while younger physicians and larger practices are most likely to push to meet MIPS requirements, said Trish Baesemann, president of AppleCare.

Such concerns about a lag in MACRA compliance followed a recent large national survey that found only one-fifth of physicians are “familiar” with the looming Medicare payment overhaul, which goes into effect in less than four months.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Thursday, September 29, 2016