Decision Health’s Part B News recently featured quotes from Vytalize Health Executive Vice President and National Medical Director John Torontow in an article about the future of ACOs and the direction they’re heading. Read the original article here.
CMS wants total ACO Medicare by 2030. Experts aren’t so sure.
By: Roy Edroso, Part B News
Published: Feb. 6, 2023
CMS is touting the growth of three accountable care organization (ACO) programs — and predicts it will meet its goal of connecting all Medicare beneficiaries to ACOs by 2030. Experts aren’t so sure, though they do think Medicare’s ACO program is heading in the right direction.
In a Jan. 17 release, “Increase in 2023 in Organizations and Beneficiaries Benefiting from Coordinated Care in Accountable Care Relationship,” CMS cites encouraging numbers from three of its ACO models: the Medicare Shared Savings Program (MSSP); ACO REACH, formerly called Direct Contracting and now CMS’ premier health equity-centered model; and Kidney Care Choices (KCC), which focuses on care for Medicare beneficiaries with chronic kidney disease (CKD) stages 4 and 5 and end-stage renal disease (ESRD), with an eye toward delaying the onset of dialysis and improving transplantation rates.
The growth CMS reports for the latter two models is impressive. ACO REACH participation shoots up from 99 groups in 2022, its last year as Direct Contracting, to 132 in 2023, with tethered beneficiaries increasing from 1.8 million to 2.1 million. This is especially strong considering the large change in model focus (PBN 2/28/22).
Rob Andrews, CEO of the Health Transformation Alliance in Collingswood, N.J., thinks ACO REACH’s successful transition is largely due to CMS’ willingness to work with providers on program design. “It was more provider sensitive [than other programs],” Andrews says. “When you have providers engaged, it’s going stimulate more consumers to be involved.”
Andrea Hurteau, chief value services officer for Duly Health and Care, a physician-directed medical group in the Midwest, says her organization had a positive experience in MSSP but was intrigued when ACO REACH was proposed and talked to Direct Contracting participants about their experience.
“Confident in our ability to take on global risk while delivering value-based outcomes, we decided the ACO reach program offered us the best alignment model for our physicians and patients,” Hurteau says.
While the Kidney Care Choices model will have the same number of entities (130) in 2023 as it had in 2022, it will include more than 8,398 participating health care providers and organizations and 249,983 beneficiaries in 2023. That marks “an 87% increase in the number of providers and organizations, [and] a 62% increase in the number of beneficiaries from 2022,” according to CMS.
All told, CMS says, the three models will involve “more than 700,000 health care providers and organizations” and “grow and provide higher quality care to more than 13.2 million people with Medicare in 2023.”
MSSP lags, for now
Numbers for MSSP, the largest and longest-lived of the programs developed by the Center for Medicare and Medicaid Innovation (CMMI), have actually declined slightly after a few years of weak recruitment (PBN 9/13/21).
Joe Caruncho, CEO of Genuine Health Group in Coral Gales, Fla., suggests “doctors who were already participating in value-based care — such as risk under Medicare Advantage contracts — didn’t see enough upside [to MSSP] since the share of savings was small.”
Shared Savings has since sweetened the deal for entrants, though, and CMS says “policies finalized in the CY 2023 Medicare Physician Fee Schedule final rule are expected to grow participation in the program for 2024 and beyond, when many of the new policies are set to go into effect” (PBN 7/25/22, 4/11/22).
That final rule included large perks for new and low-revenue accountable care organizations, including Advanced Incentive Payments to help low earners over the hump and the return of forgiving “sliding scale” performance standards for MSSP ACOs that take on risk (PBN 11/14/22).
“I don’t know that one year’s enrollment numbers are going to show a lot of progress,” Andrews says. “But as people settle in, more evangelists emerge. The greatest advocates and advertising is word of mouth among peers.”
All-ACO in 2030?
The CMS release states that the ACO “growth furthers achieving the CMS’ goal of having all people with Traditional Medicare in an accountable care relationship with their health care provider by 2030” — a goal the agency announced in 2021.
Medical group leaders who took part in a Medical Group Management Association (MGMA) poll are not so sanguine; in fact, 93% of them say Medicare has not “done enough to incentivize practices to adopt value-based care.” Experts also remain skeptical of the 100% threshold but think CMS is pushing some of the right buttons.
“I think they are making strides toward that goal,” says Mara McDermott, vice president at McDermott+Consulting in Washington, D.C., “but more can be done to ensure that there are policies that encourage continued participation by those that have been at this for a long time — like those that participated in Pioneer ACO and Next Gen ACO, or have been in MSSP for many years.”
John Torontow, M.D., MPH, executive vice president and national medical director at Vytalize Health in Hoboken, N.J., thinks the push to extend ACOs into new communities via ACO REACH and health equity components in other models is smart and necessary for growth. “When you look at where ACOs are and where they aren’t, the data are striking,” he says. “Under-resourced communities where many seniors live and get care are not in value-based contracts.”
Torontow thinks the health equity adjustment to quality scoring that CMS now offers to Shared Savings participants is another good move, as it’s “designed to get more patients served by Community Health Centers and Rural Health Centers into the program.”
Other ACO models are getting or have already gotten equity angles; KCC, for example, comes out of CMMI’s ESRD Treatment Choices (ETC) model, which CMMI advertises as “one of the first CMS Innovation Center models to directly address health equity, as social determinants of health have a significant impact on chronic kidney disease and end-stage renal disease.”
Specialty care outreach
The KCC model is also an example of CMMI’s push into the specialty space, which represents fertile ground for ACO expansion. The MGMA study found 78% of respondents “indicated that there is not a clinically relevant APM [alternative payment model] currently available for practices to participate in.”
Last year, CMMI added new models for oncology, cardiology and even children’s behavioral health (Integrated Care for Kids, aka InCK). CMMI stated in a Nov. 7, 2022, blog post that its “specialty strategy” for accountable care among specialties includes efforts to “maintain momentum established by episode payment models.” In 2018, CMMI turned its Bundled Payments for Care Improvement (BPCI) program into a voluntary ACO model (PBN 3/7/13, 1/22/18); CMMI’s long-term plan includes testing “a new mandatory acute episode payment model that improves acute care and care transitions, while supporting the goals of longitudinal, accountable care.”
CMS’ aggressive entry into the nephrology space suggests to Theresa Hush, CEO of Roji Health Intelligence, a consultancy and data registry in Chicago, that not only KCC but also other specialty-care Medicare ACO models will “turn into mandatory payment models over time.” Certain dialysis facilities billing Medicare are required to participate in ETC based on zip code; HHS says in a guidance document this includes “about a third of the nation’s dialysis facilities.” Perhaps, Hush says, CMS will “alter the APM for providers once it proves successful, like with joint replacement bundled payments.”
But CMS and CMMI also count on carrots as well as sticks to bring specialists into ACOs. Caruncho says KCC also adds an incentive to improved treatment that should draw kidney care providers who are not currently mandated into the ACO space.
“Before KCC, [ESRD] patients could negatively impact shared savings for ACOs and DCEs,” Caruncho says. “By creating a separate program with appropriate reimbursement, CMS has created an opportunity for organizations with a focus on ESRD patients to participate and benefit from providing high-quality, cost-effective care to these patients.”
About 20% of Medicare beneficiaries are currently aligned with an ACO, according to figures from the National Association of Accountable Care Organizations (NAACOS); CMS has seven years to close the gap.
CMS, “Increase in 2023 in Organizations and Beneficiaries Benefiting from Coordinated Care in Accountable Care Relationship,” Jan. 17, 2023: https://www.cms.gov/newsroom/press-releases/cms-announces-increase-2023- organizations-and-beneficiaries-benefiting-coordinated-care-accountable
HHS, “ESRD Treatment Choices (ETC) Model Performance Payment Adjustment (PPA) – Facility Component (Implementation CR),” Jan. 30, 2022: www.hhs.gov/guidance/document/esrd-treatment-choices-etc-model-performance-payment-adjustment-ppa-facility-component-0#
CMS blog, “The CMS Innovation Center’s Strategy to Support Person-centered, Value-based Specialty Care,” Nov. 7, 2022: www.cms.gov/blog/cms-innovation-centers-strategy-support-person-centered-value-based-specialty-care