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This article is part of our Essential Guide: Guide to healthcare compliance resources and agencies

Proposed CMS rule guides Shared Savings Program

A proposed rule that adds to the Medicare Shared Savings Program and offers direction to accountable care organizations is open to public comment.

In an effort to shift healthcare from a fee-for-service payment model toward a care quality-based model, CMS continues to offer support and incentives to physicians that form or join an accountable care organization. With that in mind, CMS has released a proposed rule that aims to improve care coordination within ACOs as part of the agency's Shared Savings Program. The industry can submit comments about the proposal through February 6, 2015.

More than 330 accountable care organizations (ACOs) are members of the Shared Savings Program, and there are 4.9 million beneficiaries in the participating organizations. Fifty-eight organizations that participated in the first year of the Shared Savings Program reported earning a combined $315 million in shared savings payments.

The 110-page proposed rule aims to clarify the following aspects, among others, of accountable care.

  • Requirements for ACO participant agreements, the application and application review process. This provision was added because past Shared Savings applications contained incorrect information which caused them to experience processing delays. CMS recommends ACOs view its ACO Participant Agreement Guidance to confirm their application will be accepted.
  • The identification and reporting of ACO participants. This step specifies that an ACO must include a list of all its ACO participants during the application process and submit an updated list annually.
  • Eligibility requirements based on the ACO's number of beneficiaries, structure and governing body. A section of the ACO agreement clarifies participating ACOs must "include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries" and that the amount of beneficiaries must be 5,000 at a minimum.
  • The two-sided performance-based risk tracks for ACOs. Track 1 is a shared savings only option, while track 2 applies to ACOs that take on performance-based risk. Upon reviewing these two choices, CMS has proposed the creation of a third track in which providers would accept even more performance-based risk. Track 3 ACOs would have greater incentive to improve their care quality because doing so could maximize their cut of any shared savings.
  • ACO public reporting and transparency. This can be accomplished by each ACO maintaining a website that lists the organization's name, identifies ACO participants and discloses data on their shared savings and losses owed to CMS.

The new proposed ruling is a clear indication of how important health IT is to the success of an ACO. As detailed in the document, the rule would require an ACO to outline in its application what technologies would be used to promote more coordinated care for their beneficiaries. Examples of things that could be listed in an application include the use of EHRs to track patient's data, telehealth services to remotely monitor patients and the electronic exchange of patients' health information.

CMS is working to document the success of ACOs and share insights and accomplishments with the healthcare industry to spur the creation of more accountable care groups. The proposed rule offers a template for participating ACOs to make to make certain information -- such as the identification of ACO participants, governing body members and the amount of any shared savings or shared losses incurred -- available to the public on a website that meets CMS requirements.

The need for an outcome-based payment model and a reduction in healthcare costs are the leading forces behind the creation of ACOs. Some of the first ACOs faced significant challenges during the early adoption stages due to a lack of supporting technologies and health information exchange platforms. Due to the public disclosure of ACO success stories, along with a helpful push from meaningful use criteria, physician-led groups and hospitals have a growing interest in signing up for ACOs.

About the author:
Reda Chouffani is vice president of development at Biz Technology Solutions Inc., which provides software design, development and deployment services for the healthcare industry. Let us know what you think about the story; email
 editor@searchhealthit.com or contact @SearchHealthIT on Twitter.

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