Accountable Care Organization (ACO)

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In July 2020, the Centers for Medicare & Medicaid Services (“CMS”) released part three of its ongoing Accountable Care Organization (“ACO”) Learning System and Toolkit Series: Provider Engagement Toolkit (the “Toolkit”), focusing on strategies to effectively engage healthcare providers in the ACO and in quality improvement activities.  In particular, the Toolkit showcases the various effective strategies Medicare ACOs are currently using to help primary care and specialty providers in the ambulatory setting to improve health care quality and overall patient outcomes. …
Continue Reading CMS Launches New ACO Toolkit Highlighting Effective Strategies For Achieving Provider Engagement

As discussed in our August 16, 2018 blog post, CMS Proposes Massive Changes to ACO Program – Pushing Providers to Accept Downside Risk, on August 9, 2018, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule referred to as “Pathways to Success” (the “Proposed Rule”) to redesign the Medicare Shared Savings Program (“MSSP” ). As proposed, the redesign would require Accountable Care Organizations (“ACOs”) to accept downside risk or shared losses sooner than was originally scheduled under the then-current MSSP.…
Continue Reading “Pathways to Success” Update: CMS Issues Final Rule on Changes to the ACO Program

On Thursday, August 9, 2018, the Centers for Medicare & Medicaid Services (“CMS”) published a Proposed Rule (the “Proposed Rule”)[1] regarding the Medicare Shared Savings Program (“MSSP” ) for Accountable Care Organizations (“ACOs”). The Proposed Rule would require ACOs to accept downside risk or shared losses sooner than under the current MSSP and would promote entities that have shown the greatest cost savings since implementation of the MSSP in 2012. Although not discussed in this article, the Proposed Rule also contains refinements to the methodology concerning ACO benchmarks and a modification to the current approach to risk adjustments, as well as changes to the MSSP’s claims-based assignment methodology and allowing beneficiaries to voluntarily align to ACOs in which their designated primary clinician is an ACO professional.…
Continue Reading CMS Proposes Massive Changes to ACO Program – Pushing Providers to Accept Downside Risk

On June 6th, the Centers for Medicare & Medicaid Services (CMS) released a final rule shifting how Medicare pays Accountable Care Organizations (ACO) in the Medicare Shared Savings Program.  CMS said the final rule aims to help more ACOs participate in the Medicare Shared Savings Program by improving the payment methodology and providing them with a new participation option to move into the more advanced tracks of the program. Under the final rule, Medicare will factor ACOs’ ability to deliver higher-quality care at lower cost relative to other local providers in ACOs’ reimbursements. Prior to the final rule, CMS based payment on the evaluation of an ACO’s past performance.…
Continue Reading Medicare Makes Changes to the Shared Savings Program to Strengthen Incentives for ACO Care Coordination

The IRS recently released a ruling, Private Letter Ruling (“PLR”) 201615022, denying Section 501(c)(3) tax-exempt status to a “commercial” accountable care organization (“ACO”).  This is the IRS’ first published guidance regarding a commercial ACO, and the most recent guidance from the IRS regarding the tax-exempt status of ACOs since 2011 when the IRS established that an ACO participating in the Medicare Shared Savings Program (“MSSP”) can qualify for Section 501(c)(3) status.…
Continue Reading IRS Denial of Section 501(c)(3) Status for a Commercial ACO

In line with its earlier announcement to tie increasing percentages of Medicare payments to quality and value through alternative payment models by 2018, the Centers for Medicare and Medicaid (CMS) released its final rule updating the Medicare Shared Savings Program (MSSP) and provisions relating to the payment of Accountable Care Organizations (ACOs) on June 4, 2015. CMS noted that the final rule is designed to provide additional flexibility in the MSSP and “grow participation” in the ACO alternative payment model. As CMS chief medical officer Dr. Patrick Conway noted, “Shifting from fee-for-service to accountable-care models takes time…a long-term transition [that] can certainly take more than three years. We’re really trying to meet providers where they are.”…
Continue Reading CMS Seeks to Boost ACO Participation Through New Final Rule for MSSP

On April 22, 2015, the Federal Trade Commission submitted a public letter to the New York State Department of Health (DOH) expressing “strong concerns” over state regulations offering to provide antitrust immunity to certain healthcare collaborations undertaken with DOH’s approval and supervision.  This letter is consistent with the FTC’s continued opposition to grants of immunity from federal antitrust laws based on state action.  The letter also presents a meaningful opportunity to re-evaluate the interplay between state and federal antitrust enforcement authority, and the related doctrine of state action immunity, particularly in the healthcare arena which has seen an unprecedented spike in collaborative arrangements following passage of the Affordable Care Act.…
Continue Reading State Regulatory Scheme Offering Antitrust Immunity to Healthcare Collaborations Creates Tension Between Federal and State Antitrust Enforcement

The Centers for Medicare and Medicaid (CMS) announced on March 10, 2015 that it is adding a new Accountable Care Organization (ACO) model to its cadre of innovative models.[1] Titled the “Next Generation ACO Model,” CMS’ new ACO model allows provider groups to assume higher levels of financial risk and reward than currently available under its Pioneer Model and Shared Savings Program model. CMS noted that the goal of the Next Generation ACO Model (Next Generation) is to “test whether strong financial incentives for ACOs can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.”[2]…
Continue Reading Medicare ACO v. 3.0—More Risk, More Money?

The Texas Medical Association (TMA) and Blue Cross Blue Shield of Texas are launching a new services company, TMA PracticeEdge, to facilitate bringing the benefits of value-based reimbursements to the state’s independent physicians.

Independent practitioners face challenges to participating in (and benefitting from) alternatives to fee-for-service payment, such as having the funds necessary to invest upfront in resources for improved care management. TMA PracticeEdge aims to help providers address the barriers. The company, for example, will offer consultations on basic practice management and administrative simplification, assistance with the implementation of health information technology infrastructure, and experience with risk-based contracts. Additional services will be available for practices interested in creating care teams or developing an Accountable Care Organization.

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Continue Reading New Venture Seeks to Support Independent Physicians in Texas

Some of the largest healthcare providers and insurers in the country have joined to form the Healthcare Transformation Task Force in an effort to change healthcare industry payment models.  The announcement of the task force and its efforts come shortly after the Department of Health and Human Services announced plans to overhaul Medicare’s fee-for-service program and transfer non-managed care spending to contracts that incentivize quality performance and cost control.  A unified vision of shifting to incentive based contracts has brought together health systems, Ascension, Trinity Health, Partners HealthCare, and Advocate Health Care, insurance titans Aetna and Health Care Service Corp., and Caesars Entertainment and the Pacific Business Group on Health to form the Healthcare Transformation Task Force.  The goal of the task force is to transform 75% of their business contracts to incentive based contracts focused on improving healthcare quality and lowering healthcare costs.…
Continue Reading Task Force of Healthcare Providers and Insurers are Shifting to Incentive Based Contracts