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.

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced a new primary care model aimed to improve health outcomes and better enable coordinated care with specialists to ultimately provide more seamless, high-quality, whole-person care. 

As we continue our series discussing Accountable Care Organizations, or ACOs, we now move from the topic of forming your own ACO to what are some key questions to ask before joining an existing ACO. Entering an existing ACO can be a lucrative and well aligned way to accomplish success in value based care for your MSSP patients, but you may find yourself facing buyers’ remorse if you don’t go in well-informed. If you do make a decision that doesn’t align with your practice’s priorities and goals, you will be locked into the model for at least one year, possibly more, depending on the terms of your agreement.

If you are a primary care practice, you’re most likely aware of the CMS directive to have all Medicare fee-for-service beneficiaries in an arrangement that includes accountability for quality and total cost of care by 2030. You’ve also most likely been approached within the last few weeks about joining an Accountable Care Organization (ACO), likely by multiple different groups, or you’ve done research and heard about ACOs recently. With Phase 1 of the ACO application period of May 18, 2023 through June 15, 2023 and Phase 2 July 11, 2023 through August 1, 2023, being aware of the deadlines is important, but even more important is being prepared to succeed in an ACO, and making the decision to even join one for the 2024 performance year.

If you are a primary care practice, you’ve likely been approached within the last few weeks about joining an Accountable Care Organization (ACO), possibly by multiple different groups. The reason for this flurry of activity is Phase 1 of the ACO application program goes from May 18 to June 15, 2023 and the final phase to add TINs to an ACO is July 11 to August 1, 2023. If you’re not already in an ACO, you’ll need to make some important decisions about whether or not to join an ACO for 2024, and which ACO to join. 

Health equity has become a topic of increased awareness and interest in the last several years, and CMS has most assuredly taken notice. Before you think that this is not my practice, not my concern, and not something I have to worry about, it’s best to be informed of what health equity is, what CMS is doing about it, and why health equity matters at your practice.

CMS issues an updated Advance Notice document each year, officially titled for 2024 “Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies”.

McKinsey & Company recently released A REPORT detailing the healthcare industry outlook. With inflation rates and LABOR SHORTAGES, the expected growth for healthcare profits dropped from 6% in the 2021 report to 4%. While outlooks aren’t what they were just a couple of years ago, there are certain sectors that may see higher growth–in particular, Medicare Advantage with payers, which is forecasted to see greater than 10% growth in profits.

The CMS Innovation Center (CMMI) has produced many directives recently, many of which deal with the future of value based care. A 2021 strategy statement summarized the vision of CMMI, with these two statements showing how to measure progress.

The Centers for Medicare & Medicaid Services have advanced value based care significantly in the last several years, and in a somewhat expected, yet bold move in October 2021, specifically said that they expect all traditional Medicare beneficiaries to be treated by a provider in a value-based care model by 2030. CMS rarely uses such superlative terms (all traditional Medicare beneficiaries), and the Centers for Medicare & Medicaid Services Innovation Center (CMMI) has five stated strategic objectives to achieve this massive undertaking.

Quality measures are a key aspect of primary care, not just because value-based care requires satisfaction to receive incentive payments, but because they can impact patient wellness. At a base level, it is common sense to evaluate an individual for early signs of diseases that could evolve into a more serious issue such as cancer or heart disease. Unfortunately, not all insurance payors have the same idea of what quality measures should be tracked or even what the target values should be. For example, one payor may say hypertension is defined as having a blood pressure of greater than 130/80 while another may say 140/90. Uncontrolled diabetes may be defined as an A1C greater than 8 for one payor and greater than 9 for another. A lack of consistency in these expectations causes confusion for primary care practices and can result in unmet quality measures.

It’s the beginning of a new year, so you’ll be hearing a lot about Medicare risk coding and the importance of risk coding. You’ll most likely hear the same story from many different sources - beginning January 1, those patients with amputations suddenly have limbs grow back and patients with certain conditions no longer have those conditions. You as practice leaders and physicians are told by multiple sources about how important capturing appropriate condition coding for your patients is.

The Extreme and Uncontrollable Circumstances (EUC) adjustment from CMS, also known as Covid protection, has now expired, which means that the overall star ratings for health plans will not be adjusted to account for Covid. There was an overall decline in year over year star ratings over the last two years, with the national average star rating declining from 4.37 in calendar year 2021 to 4.15 in 2022, a decline of 0.22.

You as a primary care leader are responsible to your practice and yourself for financial performance. As value based care evolves for your Medicare patients, this performance is becoming more directly linked to stars performance. There are value based care programs available from CMS directly, as well as payer-specific value based care incentives that your practice might qualify for. There are also basic, upside-only contracts from both entities and more advanced, risk-bearing contracts as your practice matures and can gain through these more advanced contracts.

Primary care, and the leaders, physicians, clinicians, and support team within those primary care offices, are truly at the heart of making healthcare better. As we close out 2022 and enter 2023, there is no better time to focus on something that’s often overlooked in the business of primary care - you and your intentions.