Summary

On September 9, 2024, Accountable for Health submitted comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Medicare Physician Fee Schedule proposed rule. Our full comments are available below. A summary of our comments follows.

Themes

1. Advancing Continuity and Stability for Accountable Care Model Participants.
2. Creating Clear and Strong Incentives for Accountable Care Participation.
3. Reducing Burden on Accountable Care Participants.
4. Rejecting Approaches that Further Fragment Care Delivery.

Specific Feedback

CMS should establish additional tracks within the Medicare Shared Savings Program that facilitate higher risk and reward for providers. Options that allow providers to share in 100% of their savings and losses, subject to a discount that guarantees savings for the federal government, have proven to be successful in improving health outcomes and lowering costs. CMS should pursue additional options that meet the needs of providers along the full spectrum of risk taking.

CMS should not finalize proposals that increase administrative burden for ACOs. CMS is proposing additional quality measure proposals that build on a recent trend of moving ACO performance standards toward fee-for-service performance standards, contrary to the intent of the Medicare Access and CHIP Reauthorization Act (MACRA), which intended to alleviate burden for physicians participating in alternative payment models (APMs).

CMS should allow ACOs to access prepaid shared savings without dictating how those funds are spent. CMS proposes allowing certain ACOs to access prepayment of their shared savings, creating revenue flow, a positive feature of the ACO movement. However, CMS proposes dictating how ACOs can use those funds, including by offering benefits such as vision, dental and hearing. A4H recommends CMS implement prepaid shared savings without dictating how those funds are used.

A4H supports long-term strategies with clear criteria to mitigate the impact of aberrant billing. ACOs and advanced APMs are well-suited to identify early aberrant billing patterns that could indicate fraud or abuse. We are pleased the agency is taking steps to ensure that ACOs are held harmless for aberrant billing behavior.

CMS should pursue strategies that encourage specialty participation in accountable care. The agency includes a request for information related to creating new MIPS Value Pathways that would allow comparisons of specific types of specialists against their peers. We recommend that CMS instead focus on more meaningful ways to remove disincentives for APM participation among specialists and continue to explore model features that encourage specialist participation.

Accountable care is an effective platform for primary care transformation. CMS is proposing to create a new tiered coding bundle for advanced primary care management. A4H recommends that if this bundle is pursued further, it must be done in careful collaboration and coordination with existing accountable care models.

Full Comment

September 9, 2024

RE: Medicare and Medicaid Programs; CY 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments (CMS-1807-P)

Submitted via regulations.gov

Dear Administrator Brooks-LaSure,

On behalf of Accountable for Health, we appreciate the opportunity to provide comments on the CY 2025 Medicare Physician Fee Schedule (PFS) proposed rule. Accountable for Health (A4H) is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.

There is strong evidence that accountable care, including Medicare’s alternative payment models, save money while simultaneously improving care for beneficiaries:

• Advanced APM accountable care organization (ACO) portfolio (ACOs that take on two-sided risk, including two-sided risk Medicare Shared Savings Program (MSSP) and CMS Innovation Center ACOs) saved $4.2 billion in traditional Medicare in 2022,¹ and a total of $8.4 billion in gross savings after taking into account spillover effects in Medicare Advantage.
• Bundled Payments for Care Improvement Advanced model reduced episode payments by 2.2% of the baseline mean for medical episodes and 4.5% for surgical episodes. The model reduced readmissions for surgical episodes by 4.1%.²
• The Comprehensive End Stage Renal Disease (ESRD) Care Model, coordinating care for individuals with ESRD, likewise, demonstrated cost savings and improved care. The model reduced Medicare spending by $217 million in traditional Medicare.³
• The Oncology Care Model generated gross savings of $499 per episode. Gross savings increased over the life of the model, and notably the level of savings accelerated over the last two performance periods. OCM led to a reduced probability of intensive care unit admission and reduced the number of emergency department visits.⁴

In addition to savings, these innovative payment arrangements have improved the patient experience. Examples include expanding access by offering more timely appointments, improving communication with patients, improving care coordination and receiving more chronic care management as compared to fee-for-service, increasing access to behavioral health services, and reducing preventable emergency room utilization.⁵

In light of these successes, A4H is pleased to see policies in the proposed rule that continue to expand adoption of effective and evidence-driven accountable care. To summarize our comments:

• CMS should adopt new tracks in the MSSP that offer higher levels of risk and reward and provide greater stability and continuity for providers taking two-sided risk;
• CMS should not finalize additional policies that increase burden on MSSP ACOs, such as revisions to quality performance measurement, and should revisit previous policies that merge the Merit-Based Incentive Payment System (MIPS) requirements into MSSP.
• CMS should finalize a pre-paid shared savings option for two-sided risk bearing ACOs but should not dictate how ACOs use those savings.
• We appreciate the development of a pathway to address SAHS billing behavior and development of a mechanism to reliably include the perspective and mitigations offered by impacted ACOs;
• A4H does not support the creation of a new MIPS MVP approach that would further silo and complicate quality measurement as a mechanism to drive specialist participation in accountable care;
• CMS should ensure that future development of primary care bundled payments and hybrid payments occur within accountable care arrangements.

Our detailed recommendations are provided below.

Medicare Shared Savings Program (MSSP)

MSSP has consistently delivered on its promise over the last decade, driving better health outcomes, improved care coordination, and reduced health care costs year over year. Today, there are MSSPACOs in every state providing services to more than 11 million beneficiaries, roughly a third of all traditional Medicare beneficiaries.⁶

Recognizing the positive impact that MSSP has for both providers seeking stable and consistent payment and patients seeking better, more coordinated care, our comments below reflect three core beliefs. First, CMS should ensure stable, predictable options for APM participation at all levels of risk and reward and should prioritize clear glide paths from one model to the next with sufficient time for providers to make decisions about model participation. Second, ACOs should have maximum flexibility in making clinical and financial decisions when caring for their aligned beneficiaries. This includes flexibility related to specific care delivery strategies, benefits decisions, and investment approaches. Third, it should be less burdensome for providers to be in an ACO than to be paid traditional fee-for-service with no alternative payment model participation.

CMS Should Establish MSSP Tracks with Higher Risk and Potential Reward

CMS seeks comment on a participation option that would allow for higher risk and reward than is currently available under the ENHANCED track. A participation option of this type would replace the existing ENHANCED track, seeking to avoid what CMS labels self-selection issues. CMS is specifically seeking comment on potential features of a revised ENHANCED track including the benchmark discount; shared savings bands; minimum savings/loss rate; payment mechanisms; and additional flexibilities or features.

A4H recommends that CMS establish additional MSSP tracks with higher risk and potential reward. These new options should be offered alongside the existing ENHANCED Track, not as a replacement. New tracks within MSSP should build on the successes and lessons learned from CMS Innovation Center ACO models over the past decade. A4H members are interested in features of two different types of MSSP options and we believe that CMS must immediately take steps to implement both in a streamlined manner to ensure minimal confusion:

• Full Risk: offers ACOs a greater share in savings and losses that are achieved by eliminating waste and improving care management, leveraging fee-for-service payments to clinicians; and
  Global Risk: offers ACOs who have successfully participated in models deploying alternative payment mechanisms, like population-based payments, a pathway to continue to deploy these successful downstream contracting and care management strategies with differentiated payment models.

Full and global risk models have demonstrated success in cost savings and care improvements. Two-sided risk models have consistently demonstrated that they improve patient care and there is strong evidence for their cost savings capabilities. Specifically, we note that many alternative payment models are scheduled to end in 2026. To afford time for businesses to plan, engage provider networks, and successfully transition to new models, full and global risk models must be announced in the next rulemaking cycle, if not sooner.

We also ask that in considering whether to add tracks and the features of those tracks, CMS prioritize model continuity for advanced APM participants. As you know, several models including Kidney Care Choices and the High Needs ACO REACH track are expiring at the end of 2026. Beneficiaries are experiencing additional benefits from these models today, including expanded access to primary care, benefit enhancements, and coordinated care to meet their unique needs. If these models are allowed to end without a smooth transition strategy, that will disrupt beneficiary care and in many instances, take away additional benefits from beneficiaries. While there are multiple potential pathways to establish this continuity, including adding tracks to the MSSP or continuing to test model design at the CMS Innovation Center, we think it is critically important to quickly and clearly communicate the plans for model evolution and continuity so that practices have time to plan for the requisite financial and staffing investments and make transitions as necessary.

Our comments on the specific questions posed by CMS are below:

What would the option of a revised ENHANCED track allow an ACO to do that they are unable to do currently?

We reiterate that we strongly recommend that CMS retain the existing ENHANCED track and plan to add alternative tracks within MSSP rather than revising the ENHANCED track. Full risk models allow ACOs to implement care transformation and innovative provider partnerships in their communities. Shared savings payments are frequently used by ACOs to reimburse providers and augment inadequate fee-for-service payment. Simply put, accountable care requires significant investment – and greater risk translates into greater resources for ACOs to pass along to providers to make these investments.

Global risk models that move away from the delivery system’s dominant reliance on fee-for-service payment systems may offer certain types of providers additional opportunities to transform care, expand partnerships, and invest in care management infrastructure in new ways. These models may provide additional tools to engage specialists and to support innovative community-based partnerships.

We believe that both full and global risk models offer opportunities to continue to transform care in new and powerful ways that improve the beneficiary experience. These models also better align with commercial and Medicare Advantage relationship structures, providing additional synergies for practices.

The reinvestment of shared savings available in full and global risk models supports sustainable job creation and practice improvements as primary care providers surround themselves with a multidisciplinary team to support whole person care. Full risk models have enabled our members to make tangible practice changes such as:

• Extended office hours to increase access to care
• Hiring nurse managers, social workers and others to provide wrap-around patient care
• Placing nurses in local emergency departments to ensure our patients get the appropriate level of care
• Establishing numerous, targeted and intensive clinical programs for patients with chronic illnesses, patients who are transitioning out of the hospital, and those who are nearing end of life
• Partnering with specialty providers to support in-home care for our sickest patients
• Onboarding new technologies and clinical infrastructures that improve patient-facing and back-end care coordination

What additional flexibilities or features (for example, benefit enhancements, advance payments, capitation payments, etc.) would ACOs in a revised ENHANCED track with higher risk and potential reward want CMS to offer to help them be successful in improving the quality of care and reducing costs?

Over the last 10-plus years, CMS has deployed successful innovations in accountable care through the CMS Innovation Center. When considering what features to add to new tracks within the MSSP, that experience should serve as a guide for features that will be successful and that helped to transform care for Medicare beneficiaries. Specifically, many of the lessons learned from the Next Generation ACO, Direct Contracting and ACO REACH models can be applied to determine what additional flexibilities and features providers would respond to and what has worked to improve care delivery.

Full Risk Track Considerations

In the development of a full risk track, we recommend the following features:

• Allow ACOs to Elect 100% Shared Savings/Losses and Choice of Savings/Loss Cap. Next Generation ACOs selected between two risk arrangement options for savings and losses: (1) partial risk, 80 percent; or (2) full risk, 100 percent. In addition, because Next Gen was a first dollar full risk model, participants had the ability to select a symmetrical cap on their savings and losses between 5 and 15 percent. The higher level of risk and reward in the Next Gen model is attractive to organizations as they continue the transition to two-sided risk.
• Infrastructure Payment and Population-Based Payment Options. Next Gens had the ability to participate in alternative payment arrangements, including infrastructure payments and population-based payment. The infrastructure payment options provide an upfront payment that is recouped against savings or in addition to losses. This structure allows smaller organizations to participate in full risk by providing investment funding upfront. In the population-based payment arrangement, certain ACO providers agree to receive reductions to their FFS reimbursements from CMS. Next Gens successfully used this option to negotiate payment arrangements with Skilled Nursing Facilities, laboratory service providers, and other entities to improve population health for their patients and drive value in their local communities. We encourage CMS to retain these options for organizations participating in the full risk offering.
• Ability to Tailor Cost Sharing Support for Part B Services. CMS allowed some Next Gen providers to reduce or eliminate cost sharing for certain Part B services for attributed beneficiaries. The goal of this benefit has been to allow ACOs to reduce financial barriers for beneficiaries, encouraging better adherence to treatment plans. CMS gives Next Gens the flexibility to identify certain beneficiaries to receive these benefits. This waiver, and the flexibility for the ACO to determine how to implement the benefit, are features of the model that should be added to MSSP for ACOs taking on performance-based risk.

Global Risk Track Considerations

Several features of the current ACO REACH model are critical to ongoing transformation among its participants. These include:

• Lower Attribution Thresholds for Participation. The ACO REACH model has introduced lower attribution thresholds that allow different types of entities to participate in accountable care initiatives and expand the reach of accountable care consistent with the agency’s 2030 goals. While the MSSP and prior ACO initiatives required at least 5,000 beneficiaries, some ACO REACH tracks allow entities to participate with substantially fewer aligned beneficiaries. This flexibility also encourages expansion into new markets. We recommend retaining that flexibility to allow a wide array of entities to participate in future models.
• Multiple Risk-Sharing Options. ACO REACH offers lower-risk sharing arrangement – 50% savings/losses with one payment option for participants, Primary Care Capitation Payment, a risk-adjusted monthly payment for primary care services provided by the ACO’s participating providers; and a higher risk sharing arrangement with 100% savings and losses that offers two payment options, Primary Care Capitation or Total Care Capitation payment, a risk-adjusted monthly payment for all services provided by the ACO’s participating providers. Flexible participation options, alongside the MSSP, allow providers to select the level of risk and payment approach most appropriate for their organization and their population. We strongly support this optionality throughout the Medicare ACO portfolio.
• Primary Care Capitation. This payment mechanism creates additional flexibility to move away from reliance on a flawed fee-for-service payment system which still dominates in traditional Medicare today. In addition, it creates cash flow necessary to transform care delivery and make important and continuous investments required to redesign the delivery system. We encourage CMS to continue to make this available as an option for participants in within the CMS accountable care portfolio.
• Claims Payment Flexibility. ACOs participating in Innovation Center models have had the ability to have certain providers reduce their claims by a percentage and instead be paid by the ACO. This population-based payment element is unique to the Innovation Center ACO portfolio and can create new and innovative payment approaches and quality accountability strategies for organizations that want to pay their contracted providers. In recent Innovation Center ACO models, participants have shown that this flexibility can be beneficial to improving care outcomes and should be retained as an option in future models.
• Streamlined set of Quality, EHR and Patient Experience Metrics. Burden reduction is a key benefit for providers who participate in accountable care models, particularly two-sided risk models. Consistent with that approach, the ACO REACH model includes a streamlined set of claims-based quality measures, which are calculated by CMS, and an attestation approach to electronic health records certification. In contrast, for example, CMS recently finalized a requirement that participants in the MSSP report the MIPS promoting interoperability performance category measures instead of the attestation requirement. This requirement adds, rather than reduces, burden for APM participants. We request that the Innovation Center retain the streamlined requirements for ACO participants whether in MSSP or a future Innovation Center model.
• Alignment Options including Paper-Based Voluntary Alignment. A key element of success for ACOs as they continue along the glidepath to greater levels of risk and reward is beneficiary engagement. Voluntary alignment strategies should continue to be an option in future ACO models at the CMS Innovation Center and MSSP. The agency should work with ACOs and beneficiary representatives to see whether these strategies can be expanded to lead to more effective participation in accountable care.

Other Features

• Participation at the TIN-NPI Level. Under MSSP regulations, CMS defines an ACO participant as an entity identified by a Medicare-enrolled billing TIN through which one or more ACO providers/suppliers bill Medicare. In other words, all providers operating under that TIN are required to be a part of the ACO. In contrast, Next Gen allowed participation at the TIN-NPI level. This flexibility allows Next Gens to create high-performing, primary care-focused networks. This flexibility should be retained for full risk models as an additional incentive to move to higher levels of risk and reward. In addition, we request that CMS use the ACO-UI system which allows participants to track participating TIN-NPIs.
• Cost Sharing Waivers for Part D and DME. CMS should consider affording additional flexibility for ACOs to cover beneficiary cost sharing, including for Part D and DME.
• Flexibility to Bypass DME Prior Authorization Requirements. While prior authorization requirements in LCDs and NCDs make sense in the context of fee-for-service, they are not necessary in the context of two-sided risk bearing ACOs.
• Waiving the statutory restrictions on Annual Wellness Visits (AWVs). Allow AWVs to be scheduled and provided once a year at any time during that calendar year. The 12-month timeline results in arbitrary barriers to care, and is also implemented differently at the discretion of the Medicare Administrative Contractors (MACs), which has caused confusion, scheduling challenges, and uncompensated care.

Should a revised ENHANCED track with higher risk and potential reward require ACOs with earned shared savings to share savings with beneficiaries or spend a flat dollar amount or a certain percentage on beneficiaries in the form of items or services not covered by original Medicare (for example, meals, dental, vision, hearing, or Part B cost-sharing reductions)?

As discussed in our response to the prepaid savings proposal below, A4H does not believe that it is appropriate for CMS to condition receipt of prepaid shared savings (i.e., revenue that an ACO has earned through its efforts to improve care and reduce costs for patients) on reinvestment in a broad set of services, including services not covered by traditional Medicare. One of the attractive features of ACO models has been the flexibility to build care management programs specific to our populations. In addition, particularly for retrospectively aligned models, requiring the addition of these types of benefits would be incredibly difficult for ACOs to administer.

How should CMS consider the discount, sharing rate, and risk corridors or marginal savings bands in the design of a higher risk option that can realize savings for Medicare? Are there special considerations that CMS should bear in mind when thinking through such features for different types of ACOs (for example, low revenue, high revenue, health system-based, safety net, etc.)?

CMS set a goal of 100% participation in accountable care relationships for the traditional Medicare population by 2030. ACO financial models should be developed with this goal in mind, providing competitive opportunities to a wide array of potential participants in its models. ACO models are voluntary for providers and therefore must strike an appropriate balance between savings to Medicare and savings to the provider community that make participation in these models worthwhile.

The agency now has substantial experience with ACO financial models developed across over a decade of model design including MSSP, Pioneer, Next Gen, Direct Contracting and ACO REACH. We recommend that CMS draw from that experience and model results, most of which have generated actuarial savings to Medicare to determine benchmarks, discounts, and risk corridors that will be attractive to participants and yield sufficient savings back to Medicare. One of the most important elements to the design of model financial parameters is predictability. CMS must leverage the options outlined in this question and the RFI more broadly to set stable and predictable financial parameters.

We believe that an overlooked consideration in developing ACO financial models and evaluations is the impact of Medicare Advantage enrollment and payment. When MSSP launched in 2012, MA enrollment was 27 percent.⁷ Today 54 percent of Medicare beneficiaries are enrolled in MA.⁸

In addition, when ACO benchmarks and evaluation strategies began, the accountable care movement was nascent. Today, about 45% of beneficiaries are in models for which CMS data is available (almost certainly representing an undercounting of model participation overall). Therefore, when CMS considers the options available to providers and patients and creating competitive offerings and realizing savings for Medicare, it must take into account broad shifts in the landscape, how models are evaluated for savings, and goals for care delivery transformation in the future.

We are interested in ways to increase participation by healthcare providers and suppliers in the Shared Savings Program and future Innovation Center ACO models, including how an ACO model requiring provider participation or stronger participation incentives might be designed.

To increase participation in MSSP and future Innovation Center ACO models, A4H recommends attention to the following:

• Continuity for model participants and populations. CMS should ensure that organizations participating in APMs have clear glidepaths and sufficient time to move from one model to the next, including contracting their provider network and communicating to their beneficiary populations. This is especially important given forecasting needs and investments to develop and refine programs.
• Rapidly incorporating successful elements of Innovation Center models into permanent programs. The Innovation Center and the Center for Medicare have a strong history of incorporating successful elements of total cost of care models into the MSSP, including prospective attribution and AIPs. When it becomes clear that a model element is successfully improving care, it should be adopted in the MSSP as quickly as possible.
• Attention to both ends of the ACO Glidepath. To reach the goal of 100% of beneficiaries in accountable care relationships by 2030, the agency must ensure that those organizations participating at the highest levels of risk continue their participation in models and that those providers that have not been early adopters understand their options and are encouraged and incentivized to participate.

CMS Should Not Finalize Additional Performance Policies for APMs that Increase Administrative Burden

CMS proposes to develop an Alternative Payment Model (APM) Performance Pathway (APP) Plus Quality Measure Set to align with the Adult Universal Foundation measures. MSSP ACOs would be required to report the measure set through Medicare Clinical Quality Measures (Medicare CQMs) and electronic CQMs (e-CQMs). MIPS CQMs would no longer be a reporting option.

The measure set would grow from six to eleven measures (six measures in the existing APP quality measure set and five newly proposed measures from the Adult Universal Foundation) over performance years 2025 through 2028. CMS would update the APP Plus quality measure set as new measures are added to or removed from the Adult Universal Foundation measure set in the future.

CMS should not finalize these proposals. While we agree that it is important to align programs around a parsimonious set of quality measures, increasing the number of quality measures that ACOs are required to report unnecessarily increases the burden associated with program participation. The promise of MACRA was that providers could assume clinical and financial risk for a population in exchange for greater flexibility and less burden. This proposal is doubly concerning as it comes at a time when CMS is quickly moving away from MIPS CQMs, which providers have already invested significant time and effort to adopt.

We are also concerned that CMS did not propose any further modification of the requirement finalized in the CY 2024 PFS to require all MSSP participants, regardless of Qualified Participant (QP) status or track, to report Merit-based Incentive Payment System (MIPS) Promoting Interoperability (PI) data starting with the 2025 performance year. We have serious concerns that these policies will significantly increase burden and jeopardize participation in the MSSP and other advanced APMs.

Overall, we are concerned by a trend that appears to be increasingly merging MIPS requirements into MSSP. The original intent of the MACRA statute was to ensure that participants in APMs of all types were subject to less burdensome requirements around performance reporting, to serve as an additional incentive to move to accountable care. The recent proposals, expanding MIPS quality reporting and adopting more burdensome Interoperability requirements appear to fly in the face of the MACRA construct that dictates a more streamlined, less burdensome approach for APM participants.

A4H Encourages CMS to Implement a Prepaid Shared Savings Option, But Recommends Giving ACOs Flexibility to Determine How to Spend Funds those Funds Support Patient Care

Starting January 1, 2026, CMS proposes to establish a new “prepaid shared savings” option for eligible ACOs with a history of earning shared savings. Eligible ACOs include those participating in Levels C-E of the BASIC track or the ENHANCED track with consistent prior success in earning shared savings in the Shared Savings Program. At least 50% of prepaid shared savings would be required to be spent on direct beneficiary services not otherwise payable by Medicare (e.g., meals, transportation, dental, vision, hearing, and Part B cost-sharing reductions).

Recognizing that participation in accountable care initiatives requires significant investment from providers, A4H strongly supports policies that provide upfront cash flow to ACOs. Fixed start-up costs, a multi-year lag between start-up and earnings, and the possibility of failure makes investing in a transition to accountable care a risk-reward proposition for providers.⁹

CMS’ current program for Advance Investment Payments (AIP) provides upfront cash flow to certain ACOs starting their accountable care journey. Providing similar cash flow mechanisms to high-performing ACOs that have demonstrated their ability to generate savings over time makes sense given that accountable care entities continue to bear significant costs over time. High-performers will also be looking for opportunities to deepen the work that they are doing in their communities, and prepaid shared savings offers an opportunity for more advanced interventions, such as paying a co-payment for a patient’s primary care or preventive services to ensure that cost is not a barrier to access.

Today, ACOs are investing their shared savings in a wide variety of activities that benefit traditional Medicare beneficiaries, clinicians, and APM entities. This includes reinvesting in care management and providers, reduce Part B cost sharing for beneficiaries, and invest in in-kind contributions – everything from minor home modifications to meals and transportation to support beneficiaries’ health care needs.

With respect to the current proposal, A4H urges CMS to make modifications to ensure that a prepaid shared savings option is attractive and operational for MSSP ACOs. We are concerned about the list of proposed additional benefits, not covered by traditional Medicare, proposed to now be paid for through ACO savings. This proposal poses cost and logistical concerns. Cost in the form of adding new benefits funded through shared savings. Logistical concerns that flow from attribution, as opposed to enrollment, benefit administration infrastructure, and the lack of existing network providers of dental, vision or hearing services accessible by ACOs today.

Additionally, we believe that a requirement for ACOs to offer additional benefits in a prescribed manner would be complicated to implement given that beneficiaries have little to no knowledge of ACO alignment. Even as ACOs are working in partnership with CMS to increase understanding, requiring ACOs to run networks of additional benefits that do not currently exist in traditional Medicare has the potential to confuse beneficiaries, especially given the likely heterogeneity in implementation across ACOs and the inability to advertise these benefits.

While our strong preference is that ACOs retain full flexibility in how to use their pre-paid shared savings, if CMS retains this requirement in the final rule, A4H urges CMS to substantially reduce the percent of prepaid savings required to be reinvested in patient benefits. MSSP ACOs have assumed clinical and financial accountability for their patients, and thus are already incentivized to invest in services and benefits for their patient population. An alternative option could be for CMS to share a portion of its share of the savings to fund these supplemental benefits, while more fully assessing and addressing the operational barriers to implementation.

A4H Supports MSSP ACO Incentives for ACOs Serving Underserved Populations

CMS proposes a health equity benchmark adjustment (HEBA) applicable to ACOs in agreement periods beginning on January 1, 2025. This upward adjustment to the historical benchmark is designed to benefit ACOs serving larger proportions of beneficiaries from underserved communities and represents a third mechanism to positively adjust the benchmark, in addition to the regional adjustment and prior savings adjustment. CMS proposes to calculate the HEBA as the multiplicative product of the HEBA scaler and the proportion of the ACO’s assigned beneficiaries who are enrolled in the Medicare Part D Low Income Subsidy (LIS) or dually eligible for Medicare and Medicaid. CMS estimates that 20 out of 456 ACOs in 2023 would receive a HEBA greater than either the prior savings adjustment or regional adjustment. CMS estimates that by performance year 2034, the proposed HEBA would likely increase program participation by 25 additional ACOs. A4H supports incentives for ACOs to serve underserved populations. Many ACOs are currently caring for patients underserved communities, making significant investments to increase access to care, improve outcomes, reduce disparities and more.

We appreciate and applaud CMS for reflecting stakeholder feedback on the HEBA in ACO REACH in this proposal for MSSP. We believe that the proposed MSSP HEBA is an improvement over the HEBA in ACO REACH as it removes the area deprivation index, which has been shown to mask disparities in certain areas.

A4H encourages CMS to continue to prioritize ACO expansion to underserved areas. While the impact of the proposed MSSP HEBA is expected to be small over time, our members stand ready to work with CMS on additional interventions that reduce health disparities across their patient populations and to support opportunities for additional investment in care infrastructure to support health care delivery in underserved areas at scale.

A4H Supports a Long-Term Strategy with Clear Criteria to Mitigate the Impact of SAHS Billing in MSSP and Urges CMS to Align These Policies with Other ACO Models

CMS proposes a methodology to account for the impact of improper payments in recalculating performance year and benchmark expenditures upon reopening a payment determination, along with a methodology for excluding payment amounts for HCPCS and CPT codes exhibiting significant, anomalous, and highly suspect (SAHS) billing activity. If CMS identifies codes with SAHS billing activity that warrant adjustment, CMS proposes to exclude all Medicare Parts A and B payment amounts associated with the identified code from expenditure and revenue calculations for the year for which the SAHS billing activity is identified. CMS would also adjust the three most recent years prior to the start of the ACO’s agreement period used in establishing the historical benchmark that is used to reconcile the ACO for a performance year corresponding to the year for which the SAHS billing activity was identified.

CMS states in the proposed rule that it will retain sole discretion for identifying SAHS activity, and that it may consider evidence from ACOs, the HHS-Office of Inspector General (OIG) and other sources in doing so. It also includes criteria that CMS will use to identify SAHS, including that the billing activity meets the SAHS definition; has national or regional impact; would result in an imbalance between ACO performance and benchmark years; and would result in inaccurate and inequitable payment determinations. CMS is not codifying these criteria but may do so in the future, and states that a “number” of criteria should be satisfied based on a “holistic assessment” of the impact of the suspected SAHS activity.

ACOs use data to analyze population health, provide information to clinicians, make specialty referrals, and otherwise facilitate decision-making to improve patient care and outcomes. This goes far beyond what is done in the unmanaged fee-for-service population because they are accountable for outcomes and cost. ACOs’ focus on data and population health information makes them uniquely situated to identify early aberrant billing patterns, unusual utilization, and spending trends. This could include comparing a physician to his or her peers, establishing thresholds or examining historical utilization patterns. Recognizing this strength, the HHS-OIG recommended prioritizing ACO referrals of potential fraud, waste, and abuse.¹⁰ We are pleased to see the agency taking steps through this rulemaking and the proposed rule on anomalous billing for CY 2023 to create pathways for recognizing this capability and for ensuring ACOs are held harmless for current and future SAHS billing activity.

A4H applauds CMS for creating a framework for the future and for addressing SAHS activity already identified in CY 2024 in a relatively fast manner. Additional clarity may be needed to further codify the criteria that CMS will use to identify SAHS activity for ACOs to clearly understand when billing activity meets the SAHS threshold and where gaps exist, ensure ACOs are afforded the opportunity to be made whole. Any scenario in which ACOs are left financial responsible for SAHS claims, whether they meet a prescribed threshold, could inadvertently deter participation in these programs or force changes to operations resulting from downward financial impacts. We also urge CMS to clarify the steps it plans to take to align with other offices in HHS and CMS when potential SAHS billing activity has been identified to ensure that ACOs do not incur losses. This may include providing ACOs the opportunity to take a more visible role in working with CMS CPI and HHS OIG to mitigate financial risk. We encourage CMS to identify opportunities to better empower ACOs and MACs to partner in mitigating SAHS claims, including the ability to withhold payment until confirmation of clinical appropriateness. Finally, we note that efforts should be taken to minimize disruption and instability for ACOs. While we fully support detecting and addressing SAHS billing activity, we note that addressing these behaviors can sometimes have unintended consequences for some ACOs, causing unintended consequences to their financial performance late in the performance year. This may include instances where NPI-level data, rather than HCPCS code data, serve as better indicators of potentially anomalous activity requiring action. We urge CMS to continue a dialogue with affected ACOs to determine what steps can be taken to maximize stability and predictability.

A4H Urges CMS to Consistently Address ACO Overlap Issues with the GUIDE Model

In 2024, MSSP will include the Guiding an Improved Dementia Experience (GUIDE) Model respite payments as medical expenses in the savings/loss calculations in MSSP, without any adjustments to the underlying benchmarks, while Innovation Center total cost of care models, including ACO REACH, will not include these payments. Respite payments represent a new set of services which are not historically paid under an existing Medicare benefit category, not represented in past claims history, and worth up to $2,500 per year for each eligible patient. Further, these payments are being made using the CMS Innovation Center’s appropriation and are not technically a Part A or B payment, which is typically required to be counted as a medical expense under 1899(d)(1)(B) of the Social Security Act. We urge the Center for Medicare to mirror the Innovation Center’s approach to REACH and other total cost of care models and exclude GUIDE respite payments in 2024 and beyond.

Quality Payment Program (QPP)

The Quality Payment Program (QPP) provides incentives for eligible clinicians to engage in advanced APMs. Advanced APMs, including some MSSP ACOs, have demonstrated that they improve quality and reduce cost as compared to the fee-for-service system.¹¹ Recognizing the opportunity to improve care for more Medicare beneficiaries, Congress included incentives for advanced APM participants. Specifically, clinicians who meet the criteria to become a QP receive a 1.88% incentive payment (originally 5%). Beginning in the 2024 performance year/2026 payment year, the incentive shifts to a differential in the conversion factor. Without an extension of the APM bonus, QPs have faced a significant cliff in their bonus payments as it transitioned from the original 5%, to 3.5%, and then reduced again to the current 1.88%. This cliff will continue as the bonus is reduced to roughly 0.5% in 2026, detracting from the movement to accountable care. Accountable for Health continues to work with Congress to reinstate and extend the APM bonus. We urge CMS to examine whether there are any additional steps that can be taken to smooth this cliff for advanced APM participants.

Linking Payment Adjustments for Specialists to the MIPS MVP Framework Will Not Have the Desired Impact of Integrating Specialists in Accountable Care

CMS outlines an approach under which they would develop an alternate pathway for specialists and sub-specialties to report through MIPS – specifically, identifying and creating a subset of measures under MIPS Value Pathways (MVP) that are tailored to specific specialties and subspecialties in a more granular way and that enable CMS to measure specialists against their peers. Like the MIPS program, payment adjustments could go up or down depending on performance.

CMS requests feedback on the design of this approach, specifically on the following: participant definition; MVP performance assessment; payment methodology; care delivery and incentives for partnerships with accountable care entities and integration with primary care; health information technology and data sharing; health equity; and multi-payer alignment.

Specialists are participating in accountable care entities and models today, as seen in the below data recently released by the Medicare Payment Advisory Commission.¹² While more must be done to deepen specialists’ engagement in and connectivity with accountable care, A4H does not believe that the MVP strategy proposed by CMS will achieve this goal. Our primary concern is around further fragmentation and competing incentives for specialists, that pull away from the goals of total cost of care models and participation in accountable care.

Rather than implement the approach included in the RFI, we recommend that CMS fix the current disincentives for APM entities to include specialists. For example, some APMs have removed specialists from their participation lists in an effort to ensure that their advanced APM entity reaches the QP thresholds. While a specialist may see some advanced APM patients, the majority of their patients may not be attributed to an advanced APM. The non-advanced APM patients would water down the entity’s performance against the threshold, potentially causing the entity not to qualify for the bonus. In response, advanced APM entities have removed specialists from their participant lists, which is the opposite of MACRA’s intent. Eliminating participation thresholds will encourage more advanced APMs to engage with specialists, supporting these providers coming off the fee-for-service chassis and increasing coordination among providers.

We also recommend that CMS consider leveraging existing approaches that have been used by ACOs today to integrate specialists into their ACOs.

Primary Care Proposals

A4H Recommends that CMS Ensure the APCM Bundle Serves as an Effective Platform to Accountable Care and Address Model Implementation Issues

CMS proposes to create a new, tiered coding bundle for advanced primary care management (APCM). These codes include an expansive set of APCM service level elements and practice-level capabilities, including expanded access to care through 24/7 access for urgent care needs; care delivery in alternate settings; comprehensive care management, including a systematic needs assessment, systems-based approaches to ensure receipt of preventive services, and medication reconciliation; developing a patient-centered comprehensive care plan, including electronic patient-centered comprehensive care plan, coordination of care transitions, timely exchange of electronic health information with other practitioners, and timely follow-up communication; and practitioner, home-, and community-based care coordination, including ongoing communications and coordination of services from practitioners, home- and community-based service providers, community-based social services providers. There is also a performance measurement component of the code set that requires providers billing the code to report through the MIPS Value in Primary Care MVP or to participate in one of the Innovation Center models.

APCM codes can be billed by the provider who serves as the “focal point” of the patient’s care if a provider chooses to bill ACPM, they may not bill a number of other codes as standalone services, including chronic care management, transitional care management, and other communications-based technology services codes.

A4H supports increased opportunities for providers to implement advanced primary care strategies throughout the Medicare program. As noted by CMS, advanced primary care has been the foundation of a number of CMS Innovation Center model tests, including the Transforming Clinical Practice Initiative, Comprehensive Primary Care and Comprehensive Primary Care+, Primary Care First, Making Care Primary, and the AHEAD model. Advanced primary care strategies are also routinely implemented by MSSP and ACO REACH ACOs.

As a threshold issue, A4H notes that there are operational issues associated with bundling these codes. Models like Making Care Primary and Primary Care First make population-based payments to model participants for a defined set of services. Some, but not all of the services identified as duplicative of APCM services are included on the list of services that are paid prospectively for these models. Additionally, the ACO REACH model includes primary care capitation for Primary Care Qualified Evaluation & Management (PQEM) services. Some but not all of these services are included on the PQEM list. The Center for Medicare will need to coordinate with the Innovation Center to ensure that APCM services are appropriately reflected in these models for payment purposes, including by introducing dynamic payment methodology that can reflect optionality (for example, if one MCP participant bills APCM, they should not be paid for the duplicative services, but if another MCP participant does not bill APCM, they should be paid for those services).

Considering the APCM bundle more holistically, we first caution that the APCM bundle itself should not be viewed as accountable care, defined as the provider taking responsibility for quality and cost. APCM should instead be viewed as a platform to support providers in the transition from fee-for-service to accountable care delivery. The extensive requirements associated with this code bundle is unnecessary in accountable care arrangements because incentives are aligned for providers to engage in these types of activities.

Nonetheless, these codes could be helpful in getting providers that are not participating in value-based care on the glidepath. As noted in the BRG white paper, “Transitioning to Value-Based Care: Financial Implications for Providers and Policymakers,¹³” participating in value-based care initiatives requires an investment on the part of providers in clinical solutions, many of which are reflected in the APCM bundle requirements. These investments include clinical solutions strategy, clinical staffing, and clinical solutions that address the health of their patient population, including care management, navigation and care coordination functionality, as well as community relationship development. They must also invest in technology solutions to support those clinical interventions, including data integration platforms, care pattern analysis software, workflow redesign tools, and technology to assist in tracking key performance indicators.

To increase APCM utilization and utility of this bundle as a springboard to accountable care, A4H recommends focusing this code set on advanced primary care services that require provider behavior change rather than simply scalability (e.g, focusing on coordinated referrals rather than 24/7 access to care or care delivered in alternate care settings). CMS should also consider whether providers in other models, such as MSSP and Kidney Care Choices, should be deemed to meet requirements, similar to ACO REACH, Making Care Primary and Primary Care First.

A4H Supports Hybrid Payment Options Within Accountable Care Arrangements

CMS seeks feedback regarding potential further evolution in coding and payment policies to better recognize advanced primary care. Specifically, CMS is requesting input on a broader set of questions related to care delivery and incentive structure alignment and five foundational components: streamlined value-based care opportunities; billing requirements; person-centered care; health equity, clinical, and social risk; and quality improvement and accountability.

Medicare’s accountable care models have demonstrated that, when properly structured and supported, they can improve care experiences, expand access, and lower costs. For example, most of Medicare’s ACO models and many specialty care models have produced savings for Medicare while also improving care through strategies such as providing more timely access to care, making it easier to find specialty care appointments, improving communication and care coordination.14 Furthermore, these models have shown that they can lower costs, with most ACO models to date generating savings back to Medicare.

A4H members support the creation of additional options that allow for different cash flow mechanisms for providers other than fee-for-service reimbursement. Hybrid payment approaches have been tested and proven successful at the CMS Innovation Center through previous advanced APM models. We believe that changing cash flow can improve health outcomes and patient satisfaction under the right circumstances. Building on this success, the CMS Innovation Center recently launched the new Primary Care ACO Flex model and continues to test the ACO REACH model, both of which test hybrid payments in the context of total cost of care accountability. We encourage Congress to continue to build on these successes.

Models that invest in advance primary care services and that test new and innovative ways of paying for those services without clinical and financial risk (i.e., Making Care Primary and Primary Care First) are not accountable care. Because of this, and given the stage of development and widespread adoption of advanced APMs today, we believe that the best way to do this is to allow hybrid payment model options within advanced APMs, as has been done at the CMS Innovation Center. Adding this flexibility to the MSSP, and potentially through other advanced APM models, would allow for this cash flow change and potential investment in care management and infrastructure without necessitating the creation of a new program requiring its own risk adjustment, quality measurement, attribution, and specialty care strategy.

We believe that adding this flexibility in the context of advanced APMs would provide a streamlined approach to ensuring beneficiary protections while advancing the goals of greater access to accountable care. In addition, we believe that many of the questions posed in the RFI will be answered through experimentation currently taking place through the CMS Innovation Center.

Behavioral Health Proposals

A4H applauds CMS for seeking comment on community-based crisis stabilization facilities, including the impact of allowing crisis stabilization units to bill Medicare under the PFS. A4H members support communities in creating and operating behavioral health crisis care systems that provide help to people when they need it most, offering an alternative to emergency departments and jails for individuals experiencing mental health and/or substance use crises. While accountable care models have improved access to and integration of behavioral health care services, lack of Medicare coverage and reimbursement often acts as a roadblock.

This lack of Medicare coverage creates a high barrier for underserved communities to adequately invest in their crisis stabilization systems; resulting in a significant funding gap that states, counties and local governments are unable to overcome. A4H urges CMS to outline how crisis stabilization units could bill Medicare under the PFS.

Conclusion

Accountable for Health appreciates the opportunity to provide feedback on this proposed rule. Please do not hesitate to contact us if we can be a resource.

Sincerely,

Mara McDermott
CEO
Accountable for Health