What You Need to Know About the CMS Pioneer ACO Model

May 23, 2011

Amid the rising tide of criticisms of the Centers for Medicare and Medicaid Services’ (CMS) proposed rules for the Medicare Shared Savings Program (MSSP), CMS and its Center for Medicare and Medicaid Innovation announced three initiatives designed to spur more rapid development of Accountable Care Organizations (ACOs) in Medicare and in the private sector. This article addresses the highlights of these new initiatives.

Pioneer ACO Model

  1. The Pioneer ACO Model is a program that will allow integrated delivery systems that are already engaged in coordinating care and participating in outcomes-based contracts with private payors to enter into agreements with Medicare to participate in a shared savings program that mirrors the MSSP, but differs in some key areas.
  2. Pioneer ACO agreements with CMS will begin in the third or fourth quarter of 2011 and, after December 31, 2012, can be extended for up to an additional four years.
  3. Pioneer ACOs will test payment models that have higher levels of shared savings and risk than the proposed MSSP.
  4. Pioneer ACOs can transition to a “population-based” or partial capitation payment model after the third year of the program if specified savings are achieved in the first two years.
  5. CMS’ goal is to enter into agreements with up to 30 Pioneer ACOs.
  6. Pioneer ACOs wishing to participate must file a letter of intent with CMS by June 10, 2011 and file an application by July 18, 2011. Forms for the letter of intent and application are available online.
  7. Pioneer ACOs must have a minimum of 15,000 Medicare beneficiaries attributed to the ACO (as opposed to only 5,000 for the MSSP).
  8. Pioneer ACOs can choose a prospective attribution model (as opposed to the retrospective model under the MSSP).
  9. Beneficiaries can be attributed to certain specialists. Where less than 10% of evaluation and management services for a beneficiary were billed by primary care physicians, the beneficiary can be attributed to certain specialists who billed for the plurality of those services. Eligible specialties include: nephrology, oncology, rheumatology, endocrinology, pulmonology, neurology, and cardiology.
  10. Pioneer ACOs will use the same quality performance measures, patient-centeredness criteria, and performance metrics as the MSSP.
  11. Eligible providers and requirements for legal status and governance structure are similar to those for the MSSP.
  12. Health information technology capabilities are identical to the MSSP (i.e., by the second performance year, at least 50% of the ACO’s primary care physicians must be “meaningful users” of a certified electronic health record).
  13. Pioneer ACOs must demonstrate that at least 50% of their total revenues are, or will be within the first two performance periods, from outcomes-based contracts that include shared savings and/or financial risk, evaluation of patient experiences of care, and quality performance incentives. Thus, Pioneer ACOs are presumed to already have significant experience with shared savings and similar programs.
  14. The Antitrust Policy Statement for the MSSP will apply to Pioneer ACOs and the Department of Health and Human Services Office of the Inspector General (OIG) and CMS are expected to apply the proposed waivers for Stark, anti-kickback, and civil monetary penalty laws.

Click here to read the entire Request for Application for Pioneer ACOs.

Advance Payment ACO Initiative

  1. The Advance Payment Initiative would allow ACOs participating in the MSSP to access a portion of their shared savings in advance in order to make capital available for investment in developing ACO infrastructure to coordinate care and meet other organizational criteria under the MSSP.
  2. ACOs would be required to submit to CMS a plan for use of the funds.
  3. Advance payments would be recouped through the ACO’s earned shared savings under the MSSP.
  4. This is only a proposal at this point and CMS is accepting comments through June 17, 2011.

Accelerated Development Learning Sessions

  1. CMS will offer four ACO Accelerated Development Learning Sessions (ADLS) in 2011.
  2. Sessions will focus on core competencies for ACO development.
  3. Sessions will not discuss elements of, or specific requirements for, participation in any CMS ACO program, including the MSSP.
  4. Attendance and materials are free of charge, but participants must pay their own travel and lodging expenses.
  5. FAQs for the ADLSs are available online as is registration for the upcoming June session.

Click here to read more from CMS about these initiatives.

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