CMS Announces New Relief for ACOS Struggling With COVID-19 Crisis

In response to an April 13, 2020 Press Launch issued by the Nationwide Affiliation of ACOs (“NAACOS”), a current NAACOS survey reveals that 56% of the survey-participating at-risk accountable care organizations (“ACOs”) – i.e., ACOs taking part in a Middle for Medicare and Medicaid Innovation (“CMMI”) different fee mannequin (“APM”) and assuming monetary threat thereunder – mentioned that they have been more likely to drop out of their APM due to their worry of getting to cowl large losses ensuing from the COVID-19 pandemic. As well as, the survey revealed that, on account of swings in unpredictability and spikes in costly hospitalizations, 21% of at-risk ACOs have been “very possible” to go away the Medicare ACO program, 14% mentioned they have been “possible,” and one other 21% mentioned they have been “considerably possible” to go away. Virtually 80% of responding at-risk ACOs mentioned they have been “very involved” about their 2020 monetary efficiency typically and the way their monetary efficiency in comparison with their relevant annual APM benchmarks.

In brief, the survey outcomes strongly recommend that the COVID-19 pandemic has been undermining the steadiness of the Medicare ACO program.

As if in a direct response to the NAACOS survey outcomes, the Facilities for Medicare and Medicaid Companies (“CMS”) has taken motion to supply at-risk ACOs with numerous types of reduction underneath their respective APM applications with a purpose to assist such ACOs via the COVID-19 healthcare disaster.

As described in our Could 1, 2020 weblog article, “CMS Updates Waivers, Offers Extra Flexibility for Suppliers Responding to COVID-19,” such CMS actions embody the issuance of an Interim Closing Rule (the “Rule”) first launched on April 28, 2020, and formally printed within the Federal Register on Could 8, 2020. The Rule supplies important monetary reduction to these at-risk ACOs taking part within the Medicare Shared Financial savings Program (“MSSP ACOs”). In response to the Rule, MSSP ACOs which are required to extend their monetary threat over their present APM contract time period could elect to keep up their present threat degree for subsequent yr in the event that they so select.

Along with the Rule, CMS Administrator Seema Verma introduced in a June 3, 2020 weblog article (the “Weblog Article”) printed in Well being Affairs that CMS could be offering MSSP ACOs and different at-risk ACOs with higher APM flexibility with a purpose to “tackle the distinctiveness of the present scenario.” CMS outlined the ACO adjustments described in Administrator Verma’s Weblog Article in a June 3, 2020 Abstract (the “CMS Abstract”)

In response to Administrator Verma, “suppliers have been enormously affected as they attempt to do the proper factor by delaying elective surgical procedures; they’ve confronted disruption in vital income streams, and concurrently skilled elevated prices for Private Protecting Gear.” Given the necessity for “transformation” as represented by the present APMs and different CMMI improvements – the necessity to “transfer our well being care system from one which pays for quantity to 1 that rewards suppliers for preserving sufferers wholesome, bettering well being outcomes, and decreasing prices” – Administrator Verma concluded that, the necessity for transformation is, “even higher as our nation confronts not simply the coronavirus however the potential of future pandemics.”

The next is a evaluation of the Weblog Article, the CMS Abstract, and the extra reduction that CMS is offering to at-risk ACOs in response to the challenges of the COVID-19 pandemic. Please be aware {that a} detailed description of every of the APMs at present in place is past the scope of this weblog publish. Such APM info can greatest be accessed on the CMS web site right here.

FUNDAMENTAL PRINCIPLES

As described within the CMS Abstract, CMS thought-about sure key ideas to find out whether or not a proposed adjustment to an APM was acceptable for implementation. Such key ideas are:

Make the most of flexibilities that exist already in present mannequin design;

Proceed enough monetary incentives that encourage greater high quality outcomes to take part in worth primarily based preparations;

Guarantee fairness and consistency throughout fashions;

Align as a lot as doable with nationwide worth primarily based and high quality fee applications;

Decrease threat to each mannequin members, the Medicaid program, and the Medicare Belief Funds:

Decrease delays in new mannequin implementation whereas offering further alternatives for participation in new fashions:

Decrease reporting burden; and

Enhances and builds off of recent CMS COVID-19 PHE flexibilities as outlined in regulation and waivers.

COVID-19 RELATED ADJUSTMENTS

In making use of the above ideas, CMS has determined to make the next changes which embody, however will not be restricted to, adjustments in monetary methodologies, mannequin timelines, and high quality reporting:

A. Monetary and Timeline Changes.

Delay Begin Date of Direct Contracting Mannequin. CMS has determined to delay the beginning date for the brand new Direct Contracting mannequin from January 1, 2020 to April 1, 2021. As described, CMS will (i) regulate any high quality benchmarks to replicate the brand new efficiency interval, and (ii) begin a brand new Direct Contracting software cycle throughout 2021 for a second cohort to launch on January 1, 2022. The delay of the beginning date and the choice to undertake a second spherical of implementation seems to be in response to complaints levied by a number of ACO associations and stakeholders that CMS has not given sufficient particulars to ACOs on the Direct Contracting mannequin.

Extending Time Durations for Subsequent Technology (“Subsequent-Gen”) Mannequin. Extending the Subsequent-Gen ACO mannequin via Dec. 2021. The Subsequent-Gen mannequin calls on ACOs to tackle extra draw back threat than within the MSSP mannequin. The mannequin sunsets on the finish of this yr, and CMS had privately informed members that it wouldn’t be again. For the 2020 efficiency yr, CMS will cut back shared losses for Subsequent-Gen ACOs through the months of the COVID-19 public well being emergency. The company additionally canceled a high quality audit for 2019 and caps the ACOs’ gross financial savings upside potential at 5%.

Extending the Oncology Care Mannequin. The Oncology Care Mannequin (“OCM”) facilities on value-based care fee preparations in oncology practices. The OCM was set to run out in June 2021. Nevertheless, as modified by CMS, the OCM will likely be prolonged for a further yr via June 2022. As well as, OCM-participating oncology practices will now have the choice to forgo upside and draw back threat efficiency for any intervals of time affected by COVID-19. Practices that proceed to take part in one- or two-sided threat could have any COVID-19 episodes faraway from reconciliation for the efficiency intervals.

Delaying Main Care First Mannequin. CMS will likely be delaying the beginning date of the intense sickness part of the Main Care First mannequin till April 1, 2021. The Main Care First-only part will nonetheless begin on January 1, 2021.

Eradicating Draw back Danger of Complete Take care of Joint Substitute. CMS will likely be eradicating the draw back threat for the Complete Take care of Joint Substitute mannequin for any episodes from January 31, 2020 via the termination of the COVID-19 emergency interval. CMS can also be extending the fifth efficiency yr via March 2021.

Danger Choices for the Bundled Funds for Care Enchancment – Superior. As described within the CMS Abstract, CMS will likely be giving members within the Bundled Funds for Care Enchancment – Superior mannequin an choice to eradicate upside or draw back dangers. Individuals that select to proceed with two-sided threat could have COVID-19 episodes of care excluded.

Extending the Complete ESRD Care Mannequin. CMS will lengthen the ESRD Care mannequin via March 31, 2021. CMS may also cut back 2020 draw back threat by lowering shared losses by the proportion of months all through the general public well being emergency interval. – i.e., No. of Emergency Months/12. CMS may also cap gross financial savings at 5% and take away the 2020 monetary assure requirement.

MSSP ACOs – Changes and Extensions. In response to the CMS Abstract, CMS has determined to take away episodes of take care of the therapy of COVID-19 for the MSSP ACO Monitor 1+ Mannequin. CMS may also permit MSSP ACOs in Monitor 1+ a voluntary election to increase their MSSP agreements for one yr via December 2021.

Delay for Kidney Care Selections Mannequin. CMS will likely be delaying the primary efficiency interval for the Kidney Care Selections to April 1, 2021. CMS may also be permitting a second cohort of ACOs to submit functions in 2021 for a January 2022 launch.

B. Changes to High quality Reporting.

Along with the modifications listed above, CMS can also be adjusting high quality assessments, equivalent to deadlines for APM participant high quality reporting and the way through which measures could also be reported, to account for the dimensions and potential prices of COVID-19.

Primarily, the flexibilities granted to Subsequent-Gen ACOs (A.2 above) and MSSP Monitor 1+ ACOs (A.Eight above) lengthen high quality reporting deadlines whereas CMS continues to observe COVID-19’s affect on 2020 high quality reporting. Such adjustments have been welcomed by the ACO group as a constructive improvement for ACOs whose general high quality measures would have seen drastic declines as a result of widespread shelter-in-place insurance policies which have induced disruptions in continual care administration and preventive care screenings.

As well as, with the brand new Direct Contracting Mannequin initiative (A.1 above), CMS will likely be adjusting any high quality benchmarks to replicate the primary cohort’s new efficiency interval anticipated to begin on April 1, 2021.

With out these changes, CMS could have confronted the lack of participation within the current APMs and a lack of curiosity on these APMs that have been set to “go reside” this yr. On this approach, the changes are well timed and are anticipated to considerably support within the monetary stability of ACOs transferring ahead amidst the operational challenges raised by COVID-19. The CMS Innovation Middle’s APM changes described right here will not be exhaustive, because the COVID-19 public well being disaster continues to evolve.

This text is just not an unequivocal assertion of the legislation, however as a substitute represents our greatest interpretation of the place issues at present stand. This text doesn’t tackle the potential impacts of the quite a few different native, state and federal orders which have been issued in response to the COVID-19 pandemic, however which aren’t referenced on this article.