ACO benchmarks being reviewed to reverse slide in participation

Adjusting for savings and improving equity are two of the main goals announced by the Centers for Medicare & Medicaid Services (CMS) to improve the way benchmarks are calculated for Accountable Care Organizations (ACOs).

Recognizing a slide in participation in the Medicare Shared Savings Program (MSSP) several CMS senior officials authored an editorial in The New England Journal of Medicine in April 2022. Given their positions of authority within the organization, their article is seen as being equivalent to a statement of strategy regarding ACO development going forward under Medicare.

In the article, the CMS representatives wrote “The Innovation Center has tested several ACO models, of which the Pioneer ACO and ACO Investment Models have achieved net savings; others, including the Advance Payment ACO Model and the Next Generation ACO Model, have not.”

The number of accountable care organizations participating in the Medicare Shared Savings Program this year is down to 477, from 561 in 2018.

Three key areas of emphasis were announced:

• “First, we plan to use the Shared Savings Program as a chassis for growth and care transformation by synchronizing key ACO features.
• “Second, CMS is committed to supporting organizations that are new to value-based care and increasing participation among small ACOs that lack experience with performance-based risk, have limited infrastructure and capital, and may need more time than larger organizations to move to two-sided risk.
• “Third, we are focused on advancing health equity by expanding the reach of ACOs into underserved communities.”

The CMS authors pointed out that “The Pioneer ACO program, which allowed providers with experience coordinating patients’ care to move more rapidly from a shared-savings payment model to a population-based payment model, was associated with significant reductions in emergency department visits and inpatient admissions.” Technology such as the primary care electronic health record (EHR) can aid in the independent physician’s population health efforts.

While most ACOs are concerned with the financial aspect, equity is also an important factor in quality healthcare delivery. Improving equity means enabling all patients within the population, regardless of race or income, to have equal access to healthcare.

To that end, the CMS article noted that there are concerns with benchmark adjustments that could make it more difficult for an ACO to care for patient populations that tend to be sicker. CMS also stated that “Black, Latinx, Asian American and Pacific Islander and American Native and Alaska Native beneficiaries have ‘had inequitable access to ACOs.’”

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The agency is also focused on improving the MSSP by syncing new ACO features. The article stated that “The [Center for Medicare and Medicaid] Innovation Center will align testing of new ACO models and features with the Shared Savings Program and will hold certain aspects, such as financial parameters, constant. Other program requirements could be waived to evaluate the effects of these changes on participation in ACOs, savings and equity.” The appropriate primary care EHR solution can aid ACOs in better realizing the full potential of healthcare technology. ACOs are trying to provide affordable care to underserved communities while also saving money for Medicare. However, providers are taking on a huge risk and if they don’t meet certain criteria or exceed their budget, then they have to pay a penalty and their budget gets lowered the next year. The result could be that they’re not able to serve the same number of underserved patients the following year. As the article pointed out, “The problem is that an ACO that reduces spending now must meet a lower benchmark that can undermine their chances of achieving savings going forward.”