Final “Pathways to Success” ACO Rules Speed Up Pace of Provider Risk

Regulation | January 03, 2019 | by Nicole Fallon

CMS has finalized new rules for current and future Medicare Accountable Care Organizations (ACOs) called “Pathways to Success,” which are designed to move ACOs to performance-based risk more quickly by replacing the current risk options of the Medicare Shared Savings Program (MSSP) ACOs with two new tracks – BASIC and ENHANCED. The rules also shorten the timeframe for (MSSP) ACOs to transition to the new ENHANCED track, which has the highest risk and reward.

As the potential downside financial risk escalates, we anticipate greater pressure to be exerted on providers participating in those ACOs to avoid hospitalizations, reduce the frequency and duration of Skilled Nursing Facility stays and improve care transitions between settings. These care delivery pattern shifts will increase the pressure on occupancy rates of Skilled Nursing Facilities providing post-acute care services. However, creative ACOs who have been approved to use a waiver of the 3-day inpatient hospital stay requirement could admit their attributed beneficiaries directly to a SNF in their network with an overall CMS rating of 3-stars or higher to avoid a hospitalization. Keep in mind, all providers under the MSSP ACOs continue to be paid directly by Medicare not the ACO.

Other final rule provisions of importance to aging services providers:

  • SNF 3-day Stay Waiver Eligibility: All MSSP ACOs in performance-based risk tracks will be eligible to apply for the SNF 3-day stay waiver regardless of their selected beneficiary assignment model. This could expand this option to more existing and new ACOs.
  • New Providers Added to SNF Affiliate category: Critical access hospitals and other small, rural hospitals operating under a swing bed agreement will now be eligible to partner with ACOs as a SNF Affiliate for the purposes of the 3-day stay waiver. 
  • Beneficiary Incentive Programs: Permits certain approved ACOs under two-sided risk models to operate a beneficiary incentive program to reward utilization of qualifying primary care services.
  • Beneficiary Notification:  ACOs must notify beneficiaries of all of an ACOs participating providers and suppliers, the beneficiary’s ability to decline claims data sharing and how the beneficiary may change who their designated primary clinician is.

The final rule replaces the existing Medicare Shared Savings Program ACO financial tracks with two new tracks – BASIC or ENHANCED.  This table describes some of the differences between and benefits of these new ACO tracks. Interested parties will need to submit a notice of intent to apply for the new models between January 2-18, 2019.