September 11, 2023

The Honorable Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Ave, SW
Washington, DC 20201

Re: Medicare & Medicaid Programs; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage, Medicare & Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program [CMS-1784-P]

Dear Administrator Brooks-LaSure,

On behalf of Accountable for Health, we appreciate the opportunity to provide comments on the Medicare Physician Fee Schedule (PFS) proposed rule. Accountable for Health 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.

Over the last several decades, accountable care has demonstrated success in expanding access, improving outcomes, enhancing care coordination, and reducing costs. Most recently, the agency announced that the Medicare Shared Savings Program (MSSP) has once again delivered shared savings and improved quality. We appreciate the agency’s policy proposals that continue to build on these successes. Overall, we are pleased to see the agency’s work to continue to improve and enhance MSSP.

Accountable for Health remains concerned about the future of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP) and its incentives to move to accountable care. As you know, the incentives for advanced alternative payment model (APM) participants face a sharp cliff in the 2024 performance/2026 payment year absent Congressional action. If allowed to go forward, the effect of dramatically reduced incentives for participation will dampen the movement to greater levels of accountability for quality and cost. We urge the Centers for Medicare & Medicaid Services (CMS) and Congress to take steps to accelerate the move to accountable care.

In addition, we support policies that expand access to behavioral health services, particularly when those services are integrated with accountable care delivery. We believe that there is tremendous potential to expand on whole-person care by ensuring that behavioral health needs are met.

Our detailed recommendations are provided below.

A4H Recommends CMS Create a Full Risk MSSP ACO Option

The Medicare Shared Savings Program (MSSP) has grown into one of the largest accountable care programs in the country, providing care to almost 11 million people with Medicare and including over 573,000 participating clinicians. The providers in MSSP have delivered better care at a lower cost for the people they serve. Earlier this year, CMS reported that MSSP accountable care organizations (ACOs) demonstrated significantly higher performance on quality measures related to diabetes and blood pressure control; breast cancer and colorectal cancer screening; tobacco screening and smoking cessation and depression screening and follow up. Furthermore, MSSP ACOs were able to achieve these improvements in quality while lowering costs, delivering savings for a sixth consecutive year. We appreciate the agency’s efforts to continue to build on these successes by expanding the program for both new participants and entities looking to take greater levels of financial risk and reward, while providing high quality care.

In the proposed rule, CMS seeks feedback on creating a higher MSSP risk track, under which the shared savings rate would be between 80 percent and 100 percent, building on the experience of the Next Generation ACO and the ACO Realizing Equity Access and Community Health (REACH) models.1 Accountable for Health supports the agency in offering additional participation options for entities that want to pursue full risk. We interpret the full risk option discussed in the PFS proposed rule to mean an ACO in which clinicians continue to be paid fee-for-service and the ACO entity can share in 100 percent savings and losses, like the Next Generation ACO model.

The Next Generation ACO model offered important lessons for the development and advancement of two-sided risk ACOs. For example, one Next Generation ACO used the Skilled Nursing Facility (SNF) three-day waiver to identify high quality SNF partners and improve patient care and outcomes.2 Another Next Generation ACO implemented a home visit program that identified beneficiaries who would benefit from a home visit and to identify social needs and provide follow-up care. The home visit program led to a reduction in unnecessary emergency department utilization and inpatient hospital admissions.3 A third Next Generation ACO used its quality improvement team to launch provider engagement activities that ultimately increased overall quality improvement and performance on specific measures, such as fall risk screening, depression screening, colorectal cancer screening and providing influenza immunization and controlling high blood pressure.4 These successes in preventive care and care improvement were empowered by the changes in clinical and financial accountability, as well as waiver flexibilities in the Next Generation ACO model. CMS now has an opportunity to build on these successes by offering a full risk track in MSSP.

There are other key differences between the Next Generation ACO model and what is available in MSSP today that we encourage CMS to consider as it designs this full risk offering. These additional features could serve as incentives to move to greater levels of risk and reward in MSSP.

  • Participation at the TIN-NPI Level. Under MSSP regulations, CMS defines an ACO participant as an entity identified by a Medicare-enrolled billing Tax Identification Number (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 MSSP ACO. In contrast, Next Generation allowed participation at the TIN-National Provider Identifier (NPI) level. This level of flexibility further allowed ACOs to create high-performing, primary care-focused networks. TIN/NPI participation also enables more flexibility in tailoring payment and delivery interventions to the capabilities and preferences of the participants, resulting in better care for beneficiaries. This flexibility should be retained for full risk models as an additional incentive to move to higher levels of risk and reward.
  • Additional waivers. The Next Generation ACO model and now the ACO REACH model have waivers that are not available to participants in MSSP. These have included post-discharge home visit waivers, care management home visit waivers and cost sharing flexibility. We encourage CMS and the CMS Innovation Center to continuously evaluate these and other waivers for inclusion, and to consider that some of these waivers could serve as an additional incentive to move groups to higher levels of risk and reward.
  • Additional Access to Data and Reporting. Managing full risk requires additional data to understand the population and the ACO’s performance. A new full-risk model should incorporate Quarterly Benchmark, Claims Lag, and Monthly Expenditure Reports with the reporting in MSSP. These reports add transparency, predictability and supports total cost of care management.

In the proposed rule, CMS asks stakeholders to comment on concerns about selective participation, i.e., that only organizations that will achieve savings will elect the full risk track, reducing the benefit to CMS. We urge the agency to reframe this consideration. Accountable care models are better for beneficiaries than fragmented, fee-for-service. Therefore, offering a robust suite of options will create opportunities for more organizations to participate and therefore more beneficiaries to receive better care as a result. The agency should encourage ACOs that succeed in accountable care to adopt higher levels of financial risk. The concerns about ensuring savings to CMS can be addressed by incorporated an appropriate level of discount, as was done in the Next Generation ACO model to ensure that CMS receives a portion of the savings.

CMS also raises concerns that full risk ACOs will avoid high risk or sicker beneficiaries. We believe that accountable care is typically the best option for high risk and sicker beneficiaries – and that shared savings results from taking better care of higher cost individuals and populations. To the extent that CMS is concerned about these practices, we believe that there is sufficient oversight (and far more so than in fee-for-service with no accountability) to identify and prevent these practices.

Incorporating a full risk ACO option is important to reach the 2030 goal of having every beneficiary in accountable care. Over the past rulemaking cycle and through the announcement of Making Care Primary, CMS has demonstrated its commitment to bringing new organizations into accountable care, especially organizations that have previously had little no experience with risk contracting. This is an important step to expand accountable care. But, to achieve the goal, it is equally important to retain and attract organizations that have longstanding experience with risk contracting and CMS models.

We also encourage the agency to adopt this option because of the signal it will send to current and future participants in Innovation Center models – that the successes from their work to transform care delivery will be incorporated into the Medicare program even if the entire model is not certified and expanded nationally. Model certification and expansion to Medicare is one pathway for the Medicare program to learn from and build on lessons of delivery system reform. But, even absent national expansion, the Innovation Center is providing valuable lessons in what works to expand access, coordinate care, and improve outcomes. These learnings should be incorporated in permanent programs wherever possible. It sends a powerful signal to model participants about the importance of their work to improve care for Americans.

In addition to the full risk track, we urge CMS to consider and begin planning for the future of the ACO REACH model. When the Next Generation ACO model ended in December 2021, many participants moved to a lower level of risk model in MSSP. Beneficiaries in these terminated Next Generation ACOs lost access to waiver flexibilities and other model design elements that were beneficial to their populations. CMS should act in a timely way, considering the timeline for ACO REACH, to ensure that no organization has to take a step backward in their risk journey when that model ends. Similarly, CMS should ensure that timelines of these offerings align and that organizations have sufficient time to plan their business and networking strategies to move from one model to the next.

One important feature of the ACO REACH model is the flexibility to modify payments to individual clinicians – rather than fee-for-service reimbursement, the ability to create alternative payment models with participant and preferred providers. This flexibility is currently unavailable in MSSP. As CMS and the Innovation Center continue to evaluate the ACO REACH model, the agency should consider developing a smooth transition pathway for those participants, which may include layering ACO REACH elements in MSSP, or offering other advanced ACO options. Our members would be pleased to serve as a resource as you continue to explore these options.

A4H Encourages CMS to allow Providers to Qualify for QP Status at the Individual Clinician and APM Entity Levels

The Quality Payment Program (QPP) provides incentives for eligible clinicians to engage in advanced alternative payment models (APMs). Advanced APMs, like some MSSP ACOs, have demonstrated that they improve quality and reduce cost as compared to fee-for-service system. 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 Qualifying Participant (QP) receive a 3.5 percent incentive (originally 5 percent). Beginning in 2026, the incentive shifts to a differential in the conversion factor. Without an extension of the APM bonus, QPs will face a significant cliff in their bonus payments as it transitions from the original 5 percent, to the current 3.5 percent, to roughly .5 percent in 2026. This cliff will detract from the movement to accountable care and should be avoided. 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.

In addition, we urge CMS to adopt policies that ensure that qualifying clinicians receive their bonuses without facing additional burden or uncertainty. Under current regulations, to become a QP (i.e., clinician that receives the bonus), an eligible clinician must be on the Participation List of an APM entity that is participating in an advanced APM. The APM entity must satisfy either the revenue or patient count threshold – ensuring that enough of its revenue or patients are flowing through the APM to qualify for the incentive payment. Once the threshold is met, the individual clinician becomes a QP. The bonus payment is made to that clinician’s TIN, which is not necessarily the same as the APM entity –in other words, MACRA intends to give the bonus to the clinician rather than to the APM entity (e.g., ACO).

CMS is proposing to shift the threshold calculation from the APM entity level to the individual clinician level.5 CMS says that it is proposing this change because the existing thresholds have discouraged some APM entities from including specialists. CMS is also concerned that there may be “free-riders” – individuals who obtain the advanced APM bonus despite providing minimal services through the APM.

While we agree that the current approach to threshold calculations is flawed and has created incentives to remove specialists from APM networks, we disagree with the proposed approach that would calculate the thresholds at the individual clinician level. Advanced APM entities have faced other challenges with the thresholds, including a lack of transparency related to the calculations that make it difficult to predict whether an APM entity will qualify or not. Shifting the existing flawed threshold calculations to the individual clinician level does not solve the problem related to the thresholds and it does not create a strong and clear incentive for specialists or other clinicians to participate in advanced APMs.

In addition, from the proposed rule, it is not clear to us whether a specialist would have sufficient data (and when) to determine whether they have qualified for the APM bonus. In the absence of that information, they would need to also submit MIPS information or risk a 9 percent penalty for failing to become a QP and failing to report MIPS. This seems to be a strong disincentive to participate in an advanced APM because it will be unclear whether they would get the bonus and necessitate reporting MIPS. One significant advantage of becoming a QP is receiving a MIPS exemption.

For MACRA’s QPP to function as intended, there need to be strong and clear incentives for the movement to advanced APMs. Ideally, incentives would be articulated in advance, paid close to when the behavior occurs, and be sufficiently strong and clearly differentiated against MIPS participation. As we continue to work with Congress on longer term fixes to MACRA, we urge CMS to consider ways of implementing the existing law that will maximize participation in advanced APMs. In addition, we urge CMS and the Innovation Center to continue to develop a comprehensive specialty care strategy, that includes incentivizing specialist participation in existing models, creating stable participation options, and strengthening data and information to support specialist engagement in accountable care.

Specific to the proposals in this rule, we recommend that CMS perform the calculation at both the entity and the individual clinician level. If the clinician qualifies under either calculation, the clinician should receive their APM bonus. The data from this policy could inform with certainty future policy as to whether some clinicians are free-riders, receiving bonuses they should not receive, but it will ensure that no clinician who should receive a bonus does not. To truly function as an incentive for participation, the mechanism to qualify for the bonus must be clear to eligible clinicians up front, which requires some familiarity with the data and the process.

A4H Opposes the Proposal to Align CEHRT Requirements for MSSP ACOs with MIPS

In enacting MACRA, Congress recognized that participants in advanced APMs were undertaking many of the desired behaviors of cost control and quality improvement through their model designs. For this reason, clinicians participating in advanced APMs who become QPs are exempt from MIPS. This longstanding policy rationale has led to CMS attempting wherever possible to remove, waive or align model requirements, removing burden or duplication in favor of empowering the movement to accountable care. We are concerned that aligning the CEHRT requirements for MSSP ACOs to MIPS is a step backward in this regard.

Currently, an ACO must attest that it meets certain requirements related to promoting interoperability. CMS is proposing to sunset the existing requirements and modify existing regulations such that MIPS requirements now apply to all clinicians participating in the ACO.6 CMS proposes that any requirements applicable to MIPS eligible clinicians reporting on objectives and measures for the MIPS promoting interoperability category would apply to clinicians in APMs and advanced APMs. CMS notes that this proposal is intended to alleviate burden because the requirements of MIPS and ACO participants are not the same.

A4H opposes this proposed change because it will create additional burden for ACOs and it is a move backward, into MIPS and away from advanced APMs. In addition, the timeline for this proposal creates challenges for ACOs because it would not be finalized until the end of the year, giving ACOs no time to address this change with their contracted networks that will already be in place before the rule is finalized.

A4H Supports Expanding Access to Behavioral Health Services and Services Addressing Health-Related Social Needs

Accountable for Health supports CMS’s actions to expand access to behavioral health services. CMS is proposing to make payments for caregiver training services, coding and payment services for health integration and social determinants of health risk assessments, and adding payment and coverage for certain mental health providers. Accountable for Health supports these steps to expand access to behavioral health services and will continue to work with our members and the agency to ensure that these new services are integrated in total cost of care delivery.


Accountable for Health appreciates the opportunity to respond to the proposed rule. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott,


Mara McDermott signature

Mara McDermott
Accountable for Health

1 Medicare & Medicaid Programs; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage, Medicare & Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program [CMS-1784-P] at 88 Fed. Reg, 52,262, at 52,492 (Aug. 7, 2023) (“PFS Proposed Rule”).
2 Centers for Medicare & Medicaid Services. Case Studies, available at (accessed September 11, 2023).
3 Centers for Medicare & Medicaid Services, Case Studies, available at (accessed Sept. 11, 2023).
4 Centers for Medicare & Medicaid Services, Case Studies, available at (accessed September 11, 2023).
5 PFS Proposed Rule, at 52,617.
6 PFS Proposed Rule at 52,433.


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