Internists Have Significant Concerns About Proposed Changes to Medicare ACOs, Note Potential Improvements

Washington, DC (August 10, 2018) — The American College of Physicians (ACP) today expressed significant concerns with the proposed rule that the Centers for Medicare & Medicaid Services (CMS) released that would drastically change the rules for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP). Under the program, groups of physician practices, hospitals and other health care professionals provide coordinated care to their Medicare beneficiary patients, with potential to share in any savings they are able to generate for the system.

The proposal would discontinue the current tracks 1, 1+, and 2—essentially bringing them together under a new BASIC track—and track 3 would then become a new ENHANCED track. Within the BASIC track, there would be a 5-level “glide path” with increasing levels of risk over the course of a 5 year contract. ENHANCED contracts would also change to a 5-year contract length and both new tracks are proposed to begin on July 1, 2019.

“The proposed changes to the MSSP are significant, and may disincentivize physicians and other health care professionals to participate in the program,” said Dr. Ana María López, MD, MPH, FACP, president, ACP.

Within the proposal, ACP has several concerns, including:

  • CMS proposes to cut the ratio of “savings” ACOs are allocated to share in by up to half.
  • The proposal only would allow an ACO to remain in a one-sided risk track, under which they are not subject to potential losses for a maximum of 2 years; groups are currently allowed to remain in one-sided risk for six years.
  • The proposal does not allow ACOs to count their cost to participate in the program as part of their financial risk—these costs average $1.6 million annually.
  • All of the proposed changes will take effect less than 11 months from now, and CMS still needs to finalize the rule.  

“Taking into account the complexity of the program, the risk that these groups take on to participate, and the substantial nature of the proposed changes, ACP is also concerned with the extremely short timeline for implementing them,” continued Dr. López. “The proposed implementation date is July 1, less than a year away; it also comes in the middle of a performance year. A major mid-year transition is likely to lead to mass confusion among ACOs.”

In addition to the items listed above, the proposal does make several promising changes that ACP has long advocated be made to the program. These include:

  • More quickly phasing in a new approach to setting benchmarks, which would avoid penalizing ACOs in high-expenditure areas.
  • More accurately adjusting risk by accounting for declines in patient health status over time, so that ACOs are not unfairly penalized for spending more on patients whose conditions have worsened.
  • Allowing any ACO to choose to have their patient population assigned at the beginning of the year (i.e., prospectively), if they would prefer that methodology over the current retrospective approach to patient attribution.

Also importantly, the proposed rule expresses CMS’s interest in gathering feedback from stakeholders about their quality measures, to reduce clinician reporting burden, promote outcomes-based measures, address opioid utilization, and improve data sharing. These goals are all in line with their Meaningful Measures program and all fall under the priorities of ACP’s Patients Before Paperwork initiative.

“ACP supports the movement to value-based payment, and we believe the ACO program is a significant piece of that movement. More than a quarter of Medicare beneficiaries receive their care in an ACO,” concluded Dr. López. “We encourage CMS to take into consideration the comments that ACP and others will be submitting as they work on the final rule, because as proposed, a considerable number of ACOs may choose to stop participating in this valuable program altogether.”


About the American College of Physicians

The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 154,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.