that would “more accurately account for the
type and intensity of E/M
work performed in primary care-focused visits,”
according to the rule.
Based on the reduced
documentation associated with the coding
proposal, CMS estimates
that practitioners will
save 51 hours a year. This
assumes a patient panel
of 20 patients a day
and a panel with 40%
to Risk-Bearing Contracts
CMS also is considering significant changes to its flagship
performance-based care program, the Medicare Shared
Savings Program (MSSP). The proposed program redesign is
intended to promote care coordination, strengthen beneficiary
engagement, and as CMS said in the proposed rule, “support
the move to value [and] achieve savings for the Medicare
program.” CMS is proposing to create a pathway to more
rapidly transition Accountable Care Organizations (ACOs) to
performance-based risk beginning July 1, 2019.
In the August 17 proposed rule, CMS intends to sunset the
current Track 1 and Track 2 ACO options. These would be
replaced with a new model, called BASIC, which offers an
incremental approach to higher levels of financial risk through
five levels, dubbed A through E. Level A and B are “upside only”
or non-risk bearing models. As ACOs transition to increasingly higher levels of risk, they eventually would reach level E.
This would match the current Track 1+ model’s financial risk
threshold and potentially qualifies as an Advanced Alternative
Payment Model (APM) under the Quality Payment Program
(QPP). BASIC ACOs would automatically advance along the
A through E continuum at the start of each new performance
year, but would have the option of advancing at a quicker pace.
For those practitioners ready to assume risk or those experienced with risk, CMS is proposing to maintain the current
Track 3 model, which will be renamed ENHANCED.
The rule also includes a number of other reforms to the
ACO program. For example, ACOs in either the BASIC or the
ENHANCED track could elect prospective assignment or
preliminary prospective assignment with retrospective rec-
onciliation. In addition, any ACO in a performance-based risk
track will qualify for the
telehealth and skilled
nursing facility waivers.
CMS also is proposing
that two-sided models
may implement a benefi-
ciary incentive program,
provided the incentive is
no more than $20 in value
and is associated with the
beneficiary’s medical care
or clinical goals.
CMS explained that the
proposed policy changes
to the MSSP are based on
five principles: account-
and quality. CMS believes
its proposed changes
will increase savings for the Medicare Trust Fund, promote
free-market principles, provide regulatory flexibility to foster
innovation within ACOs, reduce opportunities for gaming, and
improve the quality of care delivered.
Barriers to Care Coordination and Physician
Outside of the rulemaking process, CMS also indicated its willingness to reexamine its regulations surrounding the Ethics in
Patient Referral Act, more commonly known as the Stark law.
The Stark law prohibits physicians from referring patients for
“designated health services” payable by Medicare or Medicaid
from entities with which the physician or an immediate family
member has a financial relationship, unless an exception
applies. In its Stark RFI, CMS said it recognizes “care coordination is a key aspect of systems that deliver value” and that
the agency “is focused on identifying regulatory requirements
or prohibitions that may act as barriers to coordinated care.”
In response to the RFI, AMGA argued that CMS could
better manage Stark law requirements in an increasingly pay-for-performance-based reimbursement system. For example,
AMGA recommended that CMS consider allowing physicians and
groups to maintain Stark and accompanying waivers associated
with the MSSP should they exit the program but participate in
other APMs, such as Medicaid or commercial models. CMS also
should allow for Stark relief for a period of time for physicians
who exit an ACO but continue to use the ACO’s EHR.
Darryl M. Drevna, M.A., ( firstname.lastname@example.org) is director, regulatory
and public policy, and Sarah Skirmont ( email@example.com) is
government relations assistant at AMGA.
Based on the reduced documentation associated with
the coding proposal, CMS estimates that practitioners
will save 51 hours a year.