This legislation, introduced by Representatives Claudia Tenney (R-NY) and Brad Schnieder (D-IL), builds on the successes builds on the success of 10-plus years of successful ACO demonstrations at the CMS Innovation Center, across multiple Administrations, generating savings and improving health outcomes. The bill creates a permanent ACO option for organizations that want to participate in “full risk.” This program would operate as an additional option alongside the Medicare Shared Savings Program, expanding opportunities to participate in two-sided risk.
Establishment
This legislation requires the Secretary of the Department of Health and Human Services (HHS) to establish a full risk ACO program, including both a standard and a high needs track.
Full Risk ACO Program with Standard and Complex Care Track Options
This section establishes requirements for standard and high needs ACOs to participate in the full risk ACO program, defines clinical services that ACOs must provide to aligned beneficiaries, defines the minimum number of aligned beneficiaries, and requires the Secretary of HHS to establish regulations governing quality reporting and beneficiary communications.
Payment Arrangements for ACOs, Participant and Preferred Providers
Establishes payment options for participants in the full risk ACO program. Unlike the Medicare Shared Savings Program, which relies on fee-for-service payments to clinicians, this program would allow providers and ACOs to receive capitated or other alternative forms of payment. Rather than shared savings payments, this program allows full financial risk for participating ACOs subject to a discount that guarantees savings back to the Medicare Trust Fund.
In addition, this section articulates benchmarking approaches for full risk ACOs, both standard and high needs, which differ from benchmarking approaches in MSSP.
Risk Adjustment
Requires the Secretary to use prospective risk adjustment for Standard Full Risk ACOs and concurrent risk adjustment for Complex Care Full Risk ACOs to accurately reflect the risk profile of different patient populations., which differ from approaches in MSSP.
Beneficiary Assignment
Provides that beneficiaries may be aligned to Full Risk ACOs using the Medicare Shared Savings Program methodologies or with a signed voluntary agreement. This subsection also provides that Medicare beneficiaries can opt out of participating in the full risk ACO program, unlike today’s programs which only allow beneficiaries to opt out of data sharing.
Share
CMS’s 2024 results show that ACO REACH generated nearly $1 billion in net savings while improving quality and supporting better coordinated care for 2.5 million Medicare beneficiaries. This issue brief highlights the model’s growing financial performance, strong results for High Needs ACOs, and continued progress on key measures of patient care.
From uncovering abuses to securing reform, A4H led a coordinated campaign to expose waste, protect patients, and support CMS’s efforts to bring accountability to the skin substitute market.
Medicare spending on skin substitutes has grown sevenfold since 2022 – a systemic surge driven by thousands of providers nationwide, not a handful of outliers. This is not a small group of bad actors. The number of high-spend physicians has multiplied across the country.
