CMS Introduces ACO Primary Care Flex Model
by Dr. Jon Hart
The US Centers for Medicare and Medicaid Services, through their Innovation Center (CMMI) announced a new ACO program to go live in 2025 – ACO Primary Care Flex. The hope is to build on the data, experience, and successes they have had with their other models that promote primary care, but with a focus on rural and underserved regions.
Much like the “Make Care Primary” model they introduced in 2023, this model aims to assist ACOs in building a strong supportive infrastructure to help patients manage their care, in particular chronic conditions and social risks that can add to medical expense when not well controlled. With the Flex model, however, they are specifically targeting rural and underserved areas and are giving funding to ACOs up-front in order to start the building of needed programs and networks, including care at home and virtual care.
The payment model is similar to ACO REACH, in that there is a prospective, capitated payment made to the ACO designed to cover the costs associated with delivering high quality, wraparound care to Medicare beneficiaries. This payment model addresses the issue of delayed shared savings revenue in typical MSSP models, coming about 18 months after all the work has started. The predictability and proximity of this revenue is a big boost to ACOs who don’t have a big purse to carry the financing needed.
A significant difference with Flex, though, is the prospective payments amount will NOT be based on historical experience of the ACO or its members. Instead, it will depend on a County Base Rate, derived from the average primary care spending in the ACO’s county, and Enhanced Amount(s) based on characteristics of the ACO and its assigned patient population. This can be a great asset to these new programs - but there are still some concerns and questions to address until more details emerge.
Good news: the payment enhancements to the base rate will not be at risk. They are intended to provide additional support to ACOs caring for members with social risks and health disparities to increase access and care coordination.
Even more good news: each ACO will receive an upfront advanced payment of $250,000 to assist in setting up the ACO and its infrastructure for access and programming.
To participate, the entity must be a new or renewing ACO in an MSSP program in 2025, and it must be considered a “low revenue” ACO. This is a regulatory definition which basically means that the revenue of the ACO’s participating docs from fee-for-service (FFS) Medicare A & B payments cannot be above 35% of the Total FFS A & B Medicare payments for their assigned patient cohort (based on the most recent 12 months of data available).
The rationale behind this is that the low revenue ACOs tend to be made up of physician groups (not health systems) and be in more rural areas. These groups have historically performed well in MSSP ACOs with an average savings of over 5% annually.
Additional questions and concerns:
What will the quality gates be?
If a county is currently deeply underserved in primary care, will that negatively impact the County Base Rate which is derived from county primary care spending?
If all the PCPs in a rural area form an ACO and are successful in decreasing medical spend, will that negatively impact the County Base Rate? (Or will improved access to primary care account for more PCP spend in the county while decreasing overall cost of care?)
What parameters or discrete fields will be used to assess the demographics, social risks, and health disparities of the population cohort?
Will $250,000 be enough to get started if technology and reporting capabilities are severely lacking?
This could be a very good option, though, for a current MSSP in a rural or underserved area. The advance payment and the regular prospective payments could give the needed boost to get to the next level of success. I question its utility in a de novo ACO start where little infrastructure is in place, but we’ll await more details.
