New Proposed ACO Rule Change: Pathways to Success

Practical Analytic Approaches to Healthcare Challenges

On August 8, 2018, the Centers for Medicare and Medicaid Services (CMS) released a sweeping proposed regulation that, if enacted, will significantly change the Medicare Shared Savings Program (MSSP). The proposed regulation, titled “Pathways to Success,” accelerates the path for accountable care organizations (ACOs) to participate in shared risk arrangements while simultaneously softening key provisions, allowing lower revenue ACOs to participate with reduced total financial risk.

Currently the MSSP is composed of four different tracks, all with different shared saving and shared loss structures, that ACOs can enter into for a three-year agreement period.  Under the proposed rule, there would be two different tracks:  BASIC and ENHANCED each with a five-year agreement period.  Under the BASIC track, there are five different levels with various risk and reward levels that ACOs transition through during their five-year agreement period.  These various levels range from a one-sided risk model to a model that closely aligns with the current Track 1+.  The new ENHANCED track is largely the same as the existing Track 3.

In addition to these new tracks, the proposed rule affects other key program provisions.  There will also be a variety of new features available to ACOs through the proposed rule.  ACOs will be able to choose every year whether to receive prospective assignment or preliminary prospective assignment with retrospective reconciliation.  Additionally, beneficiary incentive programs, expanded telehealth services, and three-day SNF rule waivers will be supported for ACOs who are in two-sided risk arrangements under the new tracks.

If approved, the rule proposed by CMS would go into effect on July 1, 2019 for a one-time six-month performance year that would aid in the transition.  For more information about the proposed rule, reference the articles found here.