Several providers participating in Track 1 ACOs continue to urge CMS to allow them to qualify as advanced APMs under MACRA.

Dec. 19—Medicare needs to expand eligibility for a new type of accountable care organization (ACO) to include all existing ACOs or face the possibility that more of those entities could drop out, according to comments submitted by provider advocates.

In October, the Centers for Medicare & Medicaid Services (CMS) proposed a new ACO, known as the Medicare Shared Savings Program (MSSP) Track 1+ ACO, which would launch in 2018 and would qualify as an advanced alternative payment model (APM) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed ACO would feature lower risk levels than are currently available in the types of Medicare ACOs that qualify as advanced APMs. Physicians in qualifying APMs can earn 5 percent annual rate increases under MACRA and be exempt from meeting the stringent Medicare data-reporting requirements for non-APM physicians.

The new ACO will be open to providers that are unaffiliated with Medicare ACOs and those in Track 1 ACOs, which comprise 95 percent of the existing 434 MSSP ACOs.

However, provider advocates warned in comments recently submitted to CMS that barring other types of ACOs—such as MSSP Track 2 and Track 3 ACOs—from switching to Track 1+ could lead those ACOs to fold.

“Should they conclude they are unable to continue in their current ACO track/model, allowing them to participate in Track 1+ would be more beneficial for the ACOs and Medicare rather than requiring them to remain in an unsustainable situation,” wrote a provider collation that included hospital, physician, and ACO advocates. “Faced with this dilemma, many ACOs would likely drop out of the program.”

Although Medicare’s ACO program is growing, available data indicate its participants are under great financial pressure that has driven some to leave the program. For instance, only 119 out of 392 MSSP ACOs earned shared savings in performance year 2015. And only two-thirds of the ACOs scheduled to renew in 2016 opted to remain in the program, according to CMS data.

CMS has explained that Track 1+ was intended to encourage a progression to two-sided risk and to serve as an “on-ramp” to other two-sided ACO models, according to the rule in which Track 1+ was proposed. For more advanced ACOs, moving to the lower-level risk of Track 1+ could be seen as moving backward.

However, provider advocates said some of the more advanced ACOs may be facing larger losses than anticipated, and allowing them to move to Track 1+ would be better than having them leave the program as others have before them.

Provider advocates also urged that ACOs be able to move into Track 1+ at the start of any performance year instead of having to wait until their next three-year agreement period.

Track 1 Push Continues

Several providers leading Track 1 ACOs continued to urge CMS to allow them to qualify as advanced APMs under MACRA.

For instance Baylor Scott & White Health (BSWH), which has several of its quality-alliance members enrolled in MSSP Track 1 ACOs, wrote that adding Track 1 ACOs to the list of advanced APMs would adequately reward participating physicians.

“Even though downside risk is not incorporated, there are substantial financial contributions made on behalf of the ACO to operationalize an MSSP with often little likelihood of covering those expenses with shared savings dollars,” wrote Joel Allison, president and CEO of BSWH.

Additional Flexibility

Provider advocates also pushed back on the possibility that eligibility for Track 1+ ACOs could be limited based on size or provider and payer type.

“Such participation limits would unfairly disadvantage ACOs with hospital participants, those from large health systems or health-plan affiliated ACOs,” wrote the group of provider advocates, which included the National Association of ACOs and the American Hospital Association.

The groups disagreed with CMS’s previous contention that larger ACOs, those with hospital participants, and those affiliated with health plans are better-equipped to take on downside risk.

Provider advocates also pushed back on the expected time limits for Track 1+ participation.

“Limiting Track 1+ participation to a certain number of agreement periods would likely result in ACOs eventually dropping out of the program rather than assuming risk they are not prepared for,” the group wrote. “Retaining ACOs in Track 1+ would benefit ACOs and Medicare by continuing to incentivize them to enhance quality of care and generate savings for themselves and the Medicare Trust Funds. Therefore, we urge CMS not to restrict Track 1+ participation to a particular number of agreement periods.”

Other Track 1+ design elements urged by provider advocates included

  • Allowing regional financial benchmarking
  • Providing greater incentives or a higher earned shared-savings percentage compared with Track 1
  • Using either preliminary prospective or prospective beneficiary assignment
  • Allowing beneficiary attestation

Statutory Concerns

Some providers also raised concerns that MACRA’s statutory requirements could endanger the ability of ACOs and other APMs that initially qualify for the advanced APM track to remain in that track. The law set Part B payment thresholds for qualifying APMs to start at 25 percent in 2019 and increase to 75 percent in 2023 and beyond. CMS officials wrote that they expect many qualifying APMs to eventually fall short of the required thresholds.

“This prediction is troubling and negates the incentives MACRA created to encourage individual clinicians and health care organizations to volunteer to participate in innovative, risk-bearing models,” wrote Matthew Anderson, a senior vice president for the Minnesota Hospital Association.


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

Publication Date: Tuesday, December 20, 2016