CMS Official Sees Rosy Future for ACOs

CMS stands by its "bold goal" of moving 100% of Medicare beneficiaries into accountable care by 2030, according to Elizabeth Fowler, PhD, JD, deputy administrator and director for the CMS Innovation Center.

She announced plans in that regard for an advanced primary care model and other models during a speech at the National Association of ACOs (NAACOS) meeting on Friday.

In 2022, CMS acknowledged calls for reform by the House Progressive Caucus, which urged an end to CMS's ACO REACH Model (formerly known as direct contracting), citing concerns over transparency and third-party middlemen with a profit motive.

Under its redesigned model, CMS required that ACO REACH participants' governing board comprise of at least three-quarters providers, up from 25%. Each board is also required to have separate consumer and beneficiary advocates, both of which hold voting rights.

As for other accomplishments, Fowler highlighted the Innovation Center's move to embed the most effective features of its program to incentivize ACO participation in rural areas (the ACO Investment Model) into the Medicare Shared Savings Program.

She also highlighted the agency's push to strengthen the health equity component of its models by establishing a requirement that participants in certain models -- including ACO REACH -- submit health equity plans centered around strategies for addressing health disparities.

Growth, Outcomes, and Specialty Care

There have been some challenges in CMS's pursuit of moving 100% of Medicare beneficiaries into accountable care relationships with providers who are accountable for total costs of care by 2030, Fowler said.

For context, only 43% of Medicare beneficiaries were participating in ACOs as of 2021. That number had remained mostly flat since 2020. The number of Medicare beneficiaries assigned to the Medicare Shared Savings Program (MSSP) -- by far the most popular model -- actually fell slightly in recent years, dipping to 10.9 million in 2023 from 11 million in 2022, as participation declined.

Fowler said she and her colleagues expect that policies in the 2023 Physician Fee Schedule will help grow participation in 2024 and beyond.

Some of the welcome fee schedule changes included allowing ACO participants a longer glide path before taking on risk, a "health equity quality adjustment" for high-performing ACOs with underserved populations, and "fairer, more accurate financial benchmarks," according to a NAACOS press release.

As for results, the Global and Professional Direct Contracting Model model of 2021 (now ACO REACH) generated $120 million in total savings, for around 3.3% in gross spending reductions, Fowler said.

CMS received 271 applications for the ACO REACH model and entered into agreements with 48 new participants in 2023. Of the 99 participants in 2022, 84 remain in the model, she said.

Given these results and growing interest, she said, "we remain very excited about ACO REACH and the learnings this model will bring to our thinking about scaling future innovation in accountable care."

In addition, the Innovation Center has strengthened its focus on integrating specialty care in its models.

"We believe the foundation of a high-functioning health system in primary care is the root of our strategy, but given the proportion of total healthcare spending on specialty care, and that most of the care for complex high-needs beneficiaries falls to specialist providers, we know we need to do more to pull in specialists into the value-based framework," Fowler said.

To that end, the Innovation Center is taking the following steps:

• Enhancing transparency of specialist data and performance measures
• Increasing participation of episode-based payment models, particularly acute care episode-based payment models, with an eye to potentially making them mandatory in the future
• Encouraging specialists to embed in primary care focused models, (e.g., using e-consults and enhanced referrals)
• Designing financial incentives for ACOs to actively manage specialty care

Looking Ahead

In 2023, CMS plans to announce three to four new models to include an advanced primary care model, a population and condition-specific model, and a state total cost-of-care model, Fowler noted.

With regard to advanced primary care, CMS has learned that 5 years is not long enough to demonstrate the savings needed to be able to continue a model, she said.

"So we're trying a longer model test this time," she added.

The Innovation Center will also offer options for federally qualified health centers to move into value-based care. And new models will continue to focus on the goals of health equity, reaching underserved populations, integrating primary care and specialty care, and aligning payment incentives across systems to improve outcomes, she said.

In addition, CMS has opened up the application period for a 2-year extension of participation in the Bundled Payments for Care Improvement Advanced (BPCI Advanced) model. The window will close May 31.

The agency also recently conducted a survey of ACOs and various models to "guide our planning and expand our data sharing," she said.

CMS is also exploring ways to test models using the MSSP framework, Fowler noted.

"We're most successful when we're listening to you and when we're reflecting what has worked and what could work in the future," she told the audience of NAACOS members.

"So, we see this as a two-way street, where we have one ear to the ground and an eye out towards the future looking ahead, and hopefully, we're giving you enough direction to indicate where we're going."

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