AAFP Urges Modifications to CMS' Proposed ACO Rule

One Big Ask: Delay Implementation Until Jan. 1, 2020

October 31, 2018 11:20 am News Staff

In an Oct. 15 letter(25 page PDF) to CMS Administrator Seema Verma, M.P.H., the AAFP detailed what it likes and what it would like changed in CMS' proposed rule titled "Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations -- Pathways to Success" that was published in the Aug. 17 Federal Register.(www.gpo.gov)

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In the letter, signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the AAFP was particularly adamant about two specific changes and strongly urged CMS to

  • delay the implementation of all proposed policies until Jan. 1, 2020, and
  • create additional pathways to allow participation by small and rural practices.

The AAFP pointed out that family physicians participate in both the Medicare Shared Savings Program (MSSP) and accountable care organizations (ACOs), and provide the lion's share of preventive care and wellness services to millions of Medicare patients around the country.

"We are committed to working with CMS to further develop and implement physician-led, primary care focused models that increase participation in value-based care and payment models," said the AAFP.

The success of ACO models relies on a strong primary care foundation and physician leadership, noted the AAFP, and the MSSP provides an important opportunity for family physicians to participate in alternative payment models (APMs). The recommendations offered in the letter "are based on our members' experiences participating in ACOs and primary care transformation," said the AAFP.

Story Highlights
  • The AAFP has responded to CMS with suggestions on how to improve its proposed rule on accountable care organizations.
  • One of the AAFP's top requests was for CMS to delay implementation of all the proposed polices until Jan. 1, 2020.
  • The AAFP also pushed CMS to create additional pathways for participation by small and rural practices.

An AAFP staff member familiar with the proposed rule told AAFP News that CMS' proposal essentially overhauls the program. For instance, tracks one and two would be retired; tracks one-plus and three would be incorporated into the new structure with two components called basic level E and the enhanced track -- both of which would qualify as APMs.

For more details about the proposed changes, review a CMS fact sheet(www.cms.gov) released in August.

In its letter, the AAFP offered support for the creation of more APMs to give practices of all sizes more opportunity to participate.

Specifically, the Academy asked CMS to increase the glide path for new, low-revenue ACOs in the one-sided level of the basic track to three years. (CMS defines low-revenue ACOs as those most often made up of physician practices and rural ACOs.)

"It is imperative to allow ACOs, particularly physician-led and low-revenue ACOs, enough time to generate sufficient shared savings to offset startup costs and support sustained transformation," said the AAFP.

Furthermore, the AAFP pressed CMS to keep the shared savings rate at 50 percent for basic levels A-D and "offer a higher shared savings rate to support ACOs -- especially physician-led and low-revenue ACOs with more limited capital reserves -- in their efforts to improve quality and decrease costs."

In the proposed rule, CMS sought comment on how best to allow low-revenue ACOs greater access to shared savings.

The AAFP responded by noting its support for a minimum savings rate (MSR) of 1 percent for ACOs in one-sided levels of the basic track. "We also support a higher final sharing rate of 50 percent for low-revenue ACOs in the first four levels (A-D) of the basic track," said the AAFP.

The AAFP pointed out that ACOs have substantial start-up investments and that successful practices "must make organizational and operational changes as they work to improve quality and reduce cost -- with no guaranteed return on investment.

"ACOs and practices typically do not receive their shared savings until 18-24 months after the performance year, making their commitment even riskier," said the AAFP.

The letter noted that ACOs generate more savings over time. "By combining a lower MSR and higher final shared savings rate, ACOs should be able to continue to invest in new and innovative ways to improve their performance," said the AAFP.

The Academy pushed back hard on CMS' proposed revisions to the beneficiary notification section of the rule.

"The AAFP adamantly believes that proactive beneficiary notification of participation in an APM is critical to engaging patients in their care. CMS must maintain current ACO requirements for beneficiary notification. We are concerned the CMS proposal adds undue burden on ACO participants," said the letter.

The AAFP also called on CMS to, among other things,

  • transition to a real-time benefit eligibility confirmation system for physician offices that deal with billing and payment for telehealth services,
  • waive certain primary care copays for all ACO tracks, and
  • strike a proposal that would remove the current requirement that beneficiaries must receive at least one primary care service from an ACO professional who is either a primary care physician or a physician with a specialty designation before assignment to an ACO.

More From AAFP
In The Trenches blog: It's Time to Rethink Who Should be Eligible to Lead ACOs
(9/25/2018)

Accountable Care Organizations