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Shared Savings 'Pathways' final rule locks ACOs into two-sided risk after 2 years

To light a fire under Shared Savings accoutable care organizations (ACOs) that have been slow to take on double-sided risk, CMS finalized a rule today forcing them to take on that risk after two years rather than the current six.

This move has been controversial since CMS proposed it in August, with strong opinions on both sides as to whether it would build or diminish the program.

The Medicare Shared Savings Program (MSSP) currently allows ACOs six years in which to accept bonuses for delivering savings without having to pay penalties when they cost CMS money -- which would seem to defeat the purpose of an "accountable" care organization. 

CMS has tried many other, gentler means to get ACOs on board -- including training-wheels offerings such as its "Track 1+ model" with limited downside risk to lure risk-free Track 1 participants in the direction of two-sided risk. 

But, the agency points out in its new rule, issued on Dec. 21, that 82% of the 561 Shared Savings ACOs still take no risk at all.

In the new scheme, all ACOs start out in a "basic" track that locks them in for five years, the last three of which will have increasing levels of double-sided risk.

There are some exceptions: Previous Track 1 participants get only one year without risk, while "new, low revenue ACOs" may have three, risk-free years. High-performing  participants will be promoted to an "enhanced" track with higher risk-reward. 

ACOs must register for the new order between Jan. 2 and Jan. 18, 2019. (The next MSSP cycle starts on July 1, 2019, so ACOs whose term ends this year and who elected the six-month term offered in this year's physician fee schedule final rule can, if they wish, get out without overlapping with the new scheme.)

To help the ACOs succeed, CMS will allow them to charge for telehealth services "even if the otherwise applicable geographic limitations are not met, including when the beneficiary’s home is the originating site." The agency also will expand eligibility for the Skilled Nursing Facility (SNF) 3-Day Rule Waiver, and to allow ACOs to give beneficiaries an "incentive payment of up to $20" for certain primary care services they receive from the ACO network. 

The rule also makes technical changes to repayment schedules and benchmarking and aims to reduce "opportunities for gaming" by charging pro-rated shared losses to ACOs that leave the program early. 

Clif Gaus, chief executive of the National Association of Accountable Care Organizations (NAACOS), gave the final rule an overall favorable review: “We appreciate CMS’ effort in the final rule to provide greater stability to the Medicare Shared Savings Program with five-year agreement periods and more flexibility through waivers for telehealth and skilled nursing facility stays," he said in a statement. 

Blog Tags: CMS
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