NAACOS Leaders Ask CMMI to Respond to ACO Community Concerns Over Elements of New Direct Contracting Model

May 31, 2019
On May 30, the leaders at NAACOS, the ACO association, wrote a letter to CMMI Director Adam Boehler, asking him to consider a range of concerns facing ACOS, in the context of the proposed contracting model

On May 30, the leaders of Washington, D.C.-based National Association of ACOS (NAACOS) wrote a letter to Adam Boehler, Director of the Center for Medicare & Medicaid Innovation (CMMI), a division of the federal Centers for Medicare & Medicaid Services (CMS), regarding the new Direct Contracting Model whose framework CMMI had released on April 22.

As NAACOS’s leaders noted in a press release published on Thursday afternoon, “Responding to a request for information, the National Association of Accountable Care Organizations (NAACOS) today submitted feedback on the Geographic Population-Based Payment (PBP) Option, one of three options within the new Direct Contracting Model announced by the Center for Medicare and Medicaid Innovation (Innovation Center) last month. NAACOS supports introducing new alternative payment models that emphasize quality and accountability for total cost of care.”

As the press release noted, “In its letter, NAACOS urged the Innovation Center to be mindful that the Geographic PBP Option doesn’t undermine the efforts of other, now well-established, Medicare ACO models. Specifically, NAACOS is asking the Centers for Medicare & Medicaid Services (CMS) to launch the Geographic PBP Option in areas with low, if any, ACO penetration. Furthermore, ACO-assigned beneficiaries should be excluded from the populations for which Geographic Direct Contracting Entities would be responsible, so not to interfere with ACO participation.”

And the press release quoted NAACOS president and CEO Clif Gaus, Sc.D., as stating that “NAACOS appreciates the work of CMS to introduce more opportunities that move Medicare away from a fee-for-service payment system to one that rewards quality, value, and efficiency. But,” Gaus added, “CMS must recognize the tremendous growth of ACOs in Medicare and the groundwork they’ve laid for future success in this area. That work must not be disrupted, or we risk taking a step backward from the bipartisan goal of changing the way health care is delivered and paid for in this country.”

The press release noted that the Medicare Shared Savings Program (MSSP), the largest Medicare-sponsored ACO program, is in its seventh year, and is responsible for the management of the care of nearly 20 percent of all Medicare beneficiaries.

The letter from NAACOS leaders, which carries Dr. Gaus’s signature, responds to a CMMI RFI (request for information) on what is referred to as the “geographic option, in which an entity would assume financial responsibility for an entire region of Medicare patients not currently enrolled in Medicare Advantage programs.

In the letter, the NAACOS leaders write, “The National Association of ACOs (NAACOS) thanks the Center for Medicare and Medicaid Innovation (Innovation Center) for its efforts to change the way health care is paid for and delivered by implementing alternative payment models including the new Direct Contracting Model, released on April 22, 2019. The model’s three options represent another accountable care option for those ready for capitation and high levels of risk and reward. As the largest association of accountable care organizations (ACOs), representing more than 6 million beneficiary lives through more than 330 Medicare Shared Savings Program (MSSP), Next Generation Model, and commercial ACOs, NAACOS and its members are deeply committed to the transition to value-based care.”

In the letter, NAACOS members ask CMMI to skip a planned “performance year zero.” As the letter notes, “While the Direct Contracting Model begins January 2020, this Performance Year Zero is only for beneficiary alignment purposes, with performance periods in the Professional and Global PBP Model Options beginning January 2021 (Performance Year One). It is critical for CMS to allow ACOs currently participating in the MSSP or the Next Gen program to continue their current participation through 2020 and be permitted to move seamlessly into Direct Contracting in 2021. CMS could provide this option by either allowing current participants to skip Performance Year Zero or by allowing them to participate in their current initiative and the Direct Contracting Model for 2020.”

Further, the NAACOS leaders request of CMS that, “Because model overlap impacts the financial performance of providers who participate in multiple models, CMS should give precedence to the total cost-of-care models including Direct Contracting and ACO programs that may experience material financial harm in absence of protections.” Specifically, they believe that CMS will need to provide attribution and financial reconciliation preference to longitudinal, total-cost-of-care models; allow DCEs to choose if beneficiaries can also be aligned to other models; should explore options to reward providers who partner with the Innovation Center on multiple risk-based APMs; and study the impact of model overlap involved, as part of a broader evaluation of model overlaps.

Among NAACOS leaders’ other requests of CMS: that CMS retain claims processing as a voluntary option; establish accurate, predictable benchmarks; establish a fair risk adjustment methodology; utilize a reliable assignment methodology; allow flexibility around the primary care capitation around total cost of care for primary care services; implement more aggressive utilization management tools and control mechanisms; think broadly about benefit enhancements; provide fraud-and-abuse waivers; give entities access to HIPAA eligibility transaction system feeds; and reward participating organizations for higher-quality performance.

In the final paragraph of their letter to Director Boehler, the NAACOS leaders emphasize that “NAACOS supports Innovation Center efforts to transform healthcare payment and delivery systems to reward value and incentivizes quality, well-coordinated care. We appreciate the opportunity to provide feedback on how to improve these new model options,” they write. “Direct Contracting provides a chance to learn new lessons about accountable care that can be applied to the broader Medicare program. NAACOS and the Innovation Center share the goal of wanting these models to be successful, and we believe our above recommendations will create better model options.”

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