A proposed rule to refine the Medicare Shared Savings accountable care organization program to ease financial burdens on participants also includes expanded use of information technologies.

ACOs, for instance, would have flexibility “to use telehealth services as they deem appropriate for their efforts to improve care and avoid unnecessary costs,” according to the rule.

Participation in Shared Savings has been a dicey proposition for many organizations. The Centers for Medicare and Medicaid Services acknowledges that among first-year Shared Savings participants 58 held spending below their benchmarks and earned shared savings, while another 60 had expenditures below their benchmark but not enough to get shared savings.

Now, in a rule available here and being published on December 8, CMS proposes to offer a longer time period for Medicare ACOs to transition to a risk-based model, and to create a new risk-based program—called Track 3—that enables mature ACOs to assume higher risk and higher rewards. For instance, Track 3 organizations would receive a list of assigned beneficiaries at the start of the performance year, and no further beneficiaries would be added to the list.

Delivery of primary care would be expanded with more emphasis on treatment from nurse practitioners, physician assistants and clinical nurse specialists. Also, certain specialists not associated with primary care could participate in multiple ACOs.

CMS also seeks comments on care coordination tools, such as telehealth, beneficiary attestation and more flexibility with post-acute care referrals, to make risk-based ACOs more attractive. Improving care coordination, CMS says, will improve outcomes for patients and savings for ACOs and Medicare.

Consequently, CMS proposes to require applicants for the Shared Savings Program to describe in the application how they will encourage and promote use of electronic health records, telehealth services (including remote patient monitoring), health information exchange, population management and analytics software, and tools to engage patients.

“We also propose to add a new provision to require the applicant to describe how the ACO intends to partner with long-term and post-acute care providers to improve care coordination for the ACO’s assigned beneficiaries,” according to the rule.

In addition, ACOs would be required to submit milestones and targets for such projects as implementing an electronic quality reporting infrastructure, the number of providers expected to be connected to HIE services, or projected dates for implementing care coordination initiatives. These could include alert notifications on ER and hospital visits, or electronic care plans for virtual care teams. Consequently, CMS seeks comment on specific telehealth services and functions that may be appropriately adopted by ACOs.

The American Medical Group Association expressed support for expanded use of care coordination tools, but says the tools should be made available to all ACOs, not just those assuming risk.

In the proposed rule, CMS also looks to expand the types of beneficiary-identifiable data that would be provided to Shared Savings ACOs, and to simplify the claims data sharing opt-out process “to improve the timeliness of access to claims data.”

The Premier healthcare alliance applauded the proposal to enable beneficiaries to opt into an ACO program through an attestation process. “We also applaud CMS’s proposal to waive certain fee-for-service payment rules that now inhibit clinicians from using their best medical judgment as to the best time and place for care,” according to Premier. “We are also pleased that CMS appears to be willing to revisit the instability of the financial benchmarks and the inequity of the risk adjustment methodologies.” However, the risk model for ACOs remains one-sided with much work needed by CMS to even out the risks and rewards, the alliance contends.

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