CMS un­veils Medi­care-Med­i­caid ACO model

Modern Healthcare - - LATE NEWS - —Shelby Liv­ingston

The CMS will en­list states in a new ex­per­i­ment al­low­ing Medi­care ac­count­able care or­ga­ni­za­tions to also man­age Med­i­caid costs for pa­tients who are en­rolled in both pro­grams.

The new model builds on the Medi­care Shared Sav­ings Pro­gram, in which Medi­care ACOs that hit spend­ing and qual­ity tar­gets are able to share in sav­ings with the CMS. But those ACOs of­ten don’t con­sider Med­i­caid sav­ings, even when ben­e­fi­cia­ries are en­rolled in both Medi­care and Med­i­caid pro­grams. Such dual-el­i­gi­ble pa­tients of­ten are higher risk and have more ex­pen­sive health costs.

The CMS in­tends to en­ter agree­ments with as many as six states, with pref­er­ence given to states with low sat­u­ra­tion of providers al­ready par­tic­i­pat­ing in a Medi­care ACO pro­gram. Par­tic­i­pat­ing states will be able to de­sign cer­tain parts of how they im­ple­ment the model.

As of April, there were 433 ACOs in the pro­gram cov­er­ing 7.7 mil­lion pa­tients. Only a few of the par­tic­i­pat­ing ACOs are in tracks that carry the risk of los­ing money if they fail to con­trol costs. Next year, the pro­gram’s cost bench­marks will take into ac­count re­gional spend­ing fac­tors. The change was a re­sponse to com­plaints that highly ef­fi­cient providers were at a dis­ad­van­tage be­cause their per­for­mance was mea­sured against their own past re­sults.

The CMS last week also an­nounced more op­por­tu­ni­ties for clin­i­cians to join ad­vanced al­ter­na­tive pay­ment models to earn in­cen­tives un­der the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act of 2015, or MACRA.

In Jan­uary and Fe­bru­ary, the CMS will be­gin ac­cept­ing ap­pli­ca­tions for new prac­tices and pay­ers in the Com­pre­hen­sive Pri­mary Care Plus model and new par­tic­i­pants in the Next Gen­er­a­tion ACO model for 2018.

The agency ex­pects that by 2018, a quar­ter of clin­i­cians sub­ject to MACRA’s qual­ity in­cen­tive pro­gram will par­tic­i­pate in these ad­vanced pay­ment models, which re­quire par­tic­i­pants to take on sub­stan­tial down­side fi­nan­cial risk.

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