- House representatives Diane Black (R-TN) and Peter Welch (D-VT) introduced a bill last week that would change the rules for Medicare accountable care organizations (ACOs).
The ACO Improvement Act of 2016 contains reforms for Medicare Shared Savings Program (MSSP) ACOs in Track One, including prospective patient attribution, cost-sharing waivers for primary care services, and telehealth site-of-service request waivers.
The legislation includes several provisions that are designed to strengthen provider and patient relationships as well as better align Medicare beneficiaries with the ACO. If passed, Track One MSSP ACOs would have the option of receiving Medicare fee-for-service beneficiary assignments before the beginning of the performance year. Primary care providers would also be able to provide MSSP ACO information to patients.
Additionally, Medicare beneficiaries would be allowed to choose a primary care provider within the MSSP ACO to which they are assigned.
While the MSSP currently uses a retrospective beneficiary assignment strategy under Track One, some participants find it difficult to improve patient outcomes without knowing what patients are going to be aligned with the ACO before the performance year starts. The Vice President of Contracting and Risk Operations Keith Pugliese at John Muir Health, a MSSP ACO, stated in a CAPG guide from June that the program could improve by assigning patients at the start of a performance year with “with complete and timely financial, utilization, and quality data, as well as a benefit structure that incentivizes patients’ decision-making in accessing care.”
The proposed changes to the MSSP would ease the challenges of beneficiary attributions that many ACOs have experienced.
The ACO Improvement Act of 2016 also proposes to improve patient outcomes by boosting beneficiary engagement, especially through financial incentives. The legislation would allow the HHS Secretary “to reduce or eliminate cost-sharing otherwise applicable under part B for some or all primary care services (as identified by the ACO) furnished by healthcare professionals (including, as applicable, professionals furnishing services through a rural health clinic or Federally qualified health center) within the network of the ACO.”
MSSP ACOs would also be allowed to develop additional incentives to promote patient engagement and participation in the ACO, but the organizations would have to pay for the initiatives and the funds “shall not affect payments to the ACO.”
In terms of telehealth services, the bill offers waivers that would remove the originating site of service and the use of store-and-forward technologies requirements. Medicare reimbursement for telehealth services is currently limited by geographic location and site of service.
To be eligible for reimbursement, the patient must reside in a non-Metropolitan Statistical Area or a rural Health Professional Shortage Area and the services must be provided in qualifying healthcare site, such as a provider’s office, hospital, skilled nursing facility, rural health clinic, or federally qualified health centers. However, the ACO Improvement Act of 2016 would eliminate the site-of-service limitation on telehealth services if the HHS Secretary grants a waiver.
Some healthcare industry groups have been calling for telehealth waivers in Medicare ACO programs for years. In June 2014, the Alliance for Connected Care partnered with other telehealth advocate groups to urge HHS to remove regulatory barriers that hinder telehealth services. The groups noted that 80 percent of Medicare beneficiaries do not meet restrictive definitions and have no access to telehealth care.
Additionally, the legislation contains policy changes for MSSP ACOs in Track Two. Under the ACO Improvement Act of 2016, the HHS Secretary would have the authority to grant waivers that eliminate the three-day prior hospitalization requirement for skilled nursing facility services coverage. The bill would also develop waivers for the homebound requirement for home health services coverage.
The American Medical Group Association (AMGA) commended representatives Black and Welch for introducing the bill and including many of the group’s previous recommendations for improving the MSSP ACO program.
In a statement, Donald W. Fischer, PhD, CAE, AMGA President and CEO, said:
“We thank Reps. Diane Black and Peter Welch for their leadership on this legislation aimed at improving the ACO program for patients and providers. More than 100 AMGA members joined MSSP and they have improved care and reduced costs; however, they have struggled with outdated requirements. The suggested policy changes are a positive step that will improve the long term viability of the MSSP program. We look forward to continuing to work with the sponsors, Congress, and the Administration on improving the ACO program.”