Participation Requirements for Medicare ACOs

April 19, 2011

The Centers for Medicare and Medicaid Services (CMS) proposed rules for implementing the Medicare Shared Savings Program (MSSP) show that participation is not as simple as filing an application. There are a number of requirements for participation in the MSSP. Many of these requirements must be addressed in the pre-application phase and will require a significant amount of “up-front” effort in order to apply for participation. This article explores the application process and discusses some of the more significant requirements for ACOs considering participation in the MSSP.

Application Process

The proposed rules explain the application process for ACOs that want to participate in the MSSP. CMS will establish a deadline by which all applications must be submitted. CMS will approve or deny applications prior to the end of the calendar year in which the applications are submitted. It is not yet clear what the deadline will be for the first wave of ACO applications.

Pre-Application Requirements

Before any ACO applies for participation in the MSSP, it will need to ensure that it meets minimum eligibility requirements. An ACO must have in place a legal structure and governance as required by the proposed rules. Our previous article discusses legal structure and governance requirements in further detail. An ACO must also show that it has a sufficient number of primary care physicians to have an assigned beneficiary population of at least 5,000. CMS proposes that if the number of beneficiaries historically assigned over a prior three-year benchmarking period exceeds 5,000 for each year, this eligibility requirement would be met.

An ACO will also need to assess whether it is required to obtain a mandatory review from the antitrust enforcement agencies. An ACO with 50% or greater market share for any common service in a primary service area is required to undergo this mandatory review. For a more in-depth discussion of the antitrust review process see our previous article, FTC and DOJ Propose Antitrust Guidance for ACOs.

CMS also considers certain processes and internal structures necessary to operate an ACO. These include:

  1. Quality Assurance and Process Improvement Committee – The ACO must establish an ongoing, physician-directed QAPI Committee that holds ACO providers/suppliers accountable for performance.
  2. Evidence-Based Medical Practice or Clinical Guidelines – The ACO must establish and implement evidence-based medical practice or clinical guidelines and processes for delivering care consistent with the three-part aim of better care for individuals, better health for populations, and lower growth in expenditures (Three-Part Aim).
  3. HIT/EHR Infrastructure – The ACO must have an infrastructure that enables the ACO to collect and evaluate data and provide feedback to ACO participants and providers/suppliers across the entire ACO, including at the point of care. The ACO must be able to achieve “meaningful use” of electronic health records (as that term is defined by CMS) for at least 50% of its primary care physicians by the start of the ACO’s second year of performance.
  4. Compliance Plan – The ACO must have a compliance plan.
  5. Patient-Centeredness – The ACO must document processes for achieving patient-centeredness, including the ability to:
  • Conduct beneficiary experience of care surveys.
  • Evaluate the health needs of the ACO’s assigned population.
  • Identify high-risk individuals and processes to develop individualized care plans for targeted populations.
  • Coordinate care, including a process to exchange summary of care information when patients transition to another provider or setting of care, within and outside the ACO.
  • Communicate clinical knowledge/evidence-based medicine to beneficiaries in a way that is understandable to them.
  • Engage beneficiaries in shared decision-making.
  • Measure clinical or service performance by physicians across practices and use these results to improve care and service over time.
  1. Stakeholder Partnerships – The ACO must have in place partnerships with community stakeholders designed to advance the Three-Part Aim. Having a stakeholder on the governing body would be deemed sufficient.

Supporting Documentation Requirements

Along with the application itself, applicants for the MSSP will be required to submit a number of pieces of supporting documentation, including:

  1. Antitrust Agencies Letter – If applicable, the ACO must submit a letter from the antitrust agencies as described above.
  2. Repayment Mechanism – The ACO must submit documentation of an appropriate repayment mechanism to cover any losses under the MSSP, such as reinsurance, an escrow, a surety bond, or a line of credit.
  3. Leadership and Management Structure – The ACO must demonstrate that its leadership and management structure, including clinical and administrative systems, align with and support the goals of the MSSP and the Three-Part Aim.
  4. ACO Participation Documents – The ACO must submit documents (such as participation agreements, employment contracts, and operating policies) describing the ACO participants’ rights and obligations in the ACO.
  5. Quality Assurance and Process Improvement – The ACO must submit documents describing the scope, systems and scale of this program.
  6. ACO Organizational Materials – The ACO must submit an organizational chart, lists of committees and committee members, and job descriptions for senior administrative and clinical leaders.
  7. Medical Director and CMS Liaison – The ACO must identify a board-certified and licensed medical director and identify a principal CMS liaison.
  8. Disciplinary Processes – The ACO must document the remedial processes that will apply if an ACO participant or an ACO provider/supplier fails to comply with internal policies and procedures and performance standards.
  9. Compliance Plan – The ACO must submit a copy of its compliance plan.
  10. Beneficiary Communication – The ACO must submit standards for beneficiary access and communication with the ACO, including beneficiaries’ access to their medical records.
  11. Description of Distribution of Shared Savings – The ACO must describe how shared savings will be used, including distribution criteria, and how the proposed plan will achieve the goals of the MSSP and the Three-Part Aim.
  12. Patient-Centeredness – The ACO must document its plans to promote evidence-based medicine, promote beneficiary engagement, internally report quality and cost metrics, and a mechanism for coordination of care.

As this article reveals, participating in the MSSP will be a significant undertaking that will require pre-application planning and structuring to meet all of the various CMS requirements for participation.