Medicare Shared Savings Program

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The Centers for Medicare & Medicaid Services (CMS) has finalized a major restructuring of the Medicare Shared Savings Program, dubbed “Pathways to Success.”  According to CMS, the program changes “are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles.”  Most notably, CMS is accelerating the schedule for accountable care organizations (ACOs) to transition to two-sided risk models, under which the ACO is accountable for repaying shared losses in addition to qualifying for shared savings bonus payments.

By way of background, the Shared Savings Program is intended to encourage physicians, hospitals, and certain other types of providers and suppliers to form ACOs to provide cost-effective, coordinated care to Medicare beneficiaries.  The ACO agrees to be accountable for the quality and cost of the assigned Medicare fee-for-service beneficiary population.  The program has different “tracks” with varying frameworks for sharing savings or liability for losses depending on how spending compares to a benchmark.

Under the final rule, a participating ACO must select one of the following two tracks:
Continue Reading CMS Restructures Medicare Shared Savings Program to Encourage Transition to Performance-based Risk

The Centers for Medicare & Medicaid Services (CMS) is proposing a “new direction” for the Medicare Shared Savings Program, with changes to Medicare accountable care organization (ACO) requirements designed to increase Medicare savings and reduce “gaming opportunities.”  In a press release announcing the “Pathways to Success” redesign, CMS Administrator Seema Verma asserts that “after…

CMS has just put on display an interim final rule with comment period to establish special policies to assess the performance year 2017 financial and quality performance of Medicare Shared Savings Program accountable care organizations (ACOs) affected by extreme and uncontrollable circumstances, such as Hurricanes Harvey, Irma, and Maria and the California wildfires.  CMS is…

The OIG has examined the results of the first three years of the Medicare Shared Savings Program, under which accountable care organizations (ACOs) coordinate care to reduce Medicare costs and improve quality of care. The OIG reports that 428 participating ACOs serving 9.7 million beneficiaries saved almost $1 billion in net Medicare spending while generally…

The CMS Center for Medicare & Medicaid Innovation (CMMI) continues to launch initiatives to test ways to improve the quality of health care while controlling cost, despite an uncertain fate under the future Trump Administration and Republican-controlled Congress.

Specifically, two new CMMI Beneficiary Engagement and Incentives (BEI) Models seek to promote “shared decision making,” which…

In order to improve “clinician engagement” and minimize administrative burdens, CMS has announced an 18-month pilot program to reduce medical review audits for participants in selected Advanced Alternative Payment Models (Advanced APMs), beginning January 1, 2017. Under this program, CMS will direct Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and the Supplemental Medical Review…

CMS is hosting a call on November 1, 2016 to discuss how physicians and other providers can report quality measures during 2016 to maximize participation in Medicare quality programs, including the Physician Quality Reporting System (PQRS), Medicare Electronic Health Record (EHR) Incentive Program, Value-Based Payment Modifier (Value Modifier), and the Medicare Shared Savings Program.

On March 3, CMS is hosting a “listening session” to receive feedback on proposed changes to the Medicare Shared Savings Program benchmarking methodology published on February 3, 2016. In particular, CMS invites comments on provisions addressing:

  • Incorporation of regional fee-for-service expenditures into the methodology for resetting accountable care organizations’ (ACO) historical benchmark;
  • Adjustments to an

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On February 3, 2016, CMS published a proposed rule that would revise the methodology CMS uses to measure the performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program (Shared Savings Program) in order to encourage participation in the program.  In particular, the proposed rule would modify the methodology CMS uses to reset…

On December 8, 2015, CMS is hosting a call to discuss how the 2016 Medicare Physician Fee Schedule final rule impacts Medicare quality reporting programs.  Specifically, the call will address changes to the Physician Quality Reporting System, the Electronic Health Record Incentive Program, the Comprehensive Primary Care initiative, the Value-Based Payment Modifier, the Medicare Shared…

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have finalized a rule designed to “remove legal and regulatory barriers that can impede care coordination in furtherance of the Shared Savings Program” and “reduce burden on ACOs, ACO participants, and ACO providers/suppliers.”  Specifically, the rule allows ACOs, ACO participants, and ACO providers/suppliers to seek to comply with one or more specified waivers so that they have assurance that participating in certain arrangements would not subject them to liability under the physician self-referral law (Stark Law), federal anti-kickback statute, or the beneficiary inducements civil monetary penalties (CMP) law provision.  According to CMS, the waivers “are critical to providing stakeholders with flexibility necessary for innovative care redesign.”
Continue Reading CMS/OIG Finalize Fraud Authority Waivers for Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP)

On July 15, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to update the Medicare physician fee schedule (MPFS) for CY 2016 – the first rulemaking since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the sustainable growth rate (SGR) formula.  Under the proposed rule, the 2016 MPFS conversion factor (CF) would be $36.1096, compared with the 2015 CF of $35.9335, reflecting a 0.5% update factor specified under MACRA and a budget neutrality adjustment of 0.9999.  Note that the CF is subject to change in the final rule, however, if CMS does not meet a statutory target for expenditure reductions related to its review of misvalued procedures (discussed below). The proposed rule addresses numerous aspects of Medicare Part B and other CMS program policies.  Highlights include the following: 
Continue Reading Proposed CY 2016 MPFS Rule Takes First Steps in Implementing MACRA Reforms

As previously reported, CMS announced a Medicare Shared Savings Program/Accountable Care Organization (ACO) “Investment Model” last fall to better coordinate care in rural and underserved areas where inadequate access to capital could hinder infrastructure development needed for successful population care management. On June 25, 2015, CMS announced that it is modifying the eligibility criteria…

On June 9, 2015, CMS published a final rule revising the regulations governing the Medicare Shared Savings Program, which is intended to encourage physicians, hospitals, and certain other types of providers and suppliers to form Accountable Care Organizations (ACOs) to provide cost-effective, coordinated care to Medicare beneficiaries. According to CMS, the Shared Savings Program now includes more than 400 ACOs serving more than 7 million Medicare fee for service (FFS) beneficiaries.

Under current rules, ACOs can participate in two tracks: Track 1, a “one-sided” risk model under which ACOs qualify to share in program savings but are not responsible for losses; and Track 2, a “two-sided” model under which ACOs may qualify to share in savings with an increased sharing rate, but also must take on risk for sharing in losses. The final rule revises the schedule for ACOs to transition to performance-based risk arrangements and makes other changes in program regulations to emphasize primary care services, reduces the administrative burden on participants, and improves program function and transparency. Specifically, the final rule, among other things:Continue Reading CMS Adopts Changes to Medicare Shared Savings Program/ACO Regulations

CMS is proceeding with the application process for the Medicare Shared Savings Program for the January 1, 2016 program start date. Applicants interested in participating must submit a Notice of Intent to Apply by May 29, 2015, and complete the application by July 31, 2015.  A CMS call regarding the Shared Savings Program application review…

On March 10, 2015, CMS announced the Next Generation Accountable Care Organization (ACO) Model, its latest Affordable Care Act (ACA) innovation initiative intended to promote Medicare quality improvement and care coordination. The Next Generation ACO Model differs from the existing Medicare Shared Savings Program and Pioneer ACO models in several ways. For instance, the Next…