Medicare leaders discuss accountable care growth as part of NAACOS conference

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Medicare leaders say they are committed to helping accountable care organizations work toward agency’s 2030 goal of having 100% of traditional Medicare beneficiaries in accountable care relationships.

Three top leaders within the U.S. Centers for Medicare & Medicaid Services spoke during the opening plenary of the 2024 spring conference of the National Association of Accountable Care Organizations (NAACOS). Association President and CEO Clif Gaus, ScD, spoke with Meena Seshamani, MD, PhD, deputy administrator and director of the Center for Medicare; Dora Hughes, MD, MPH, acting chief medical officer and acting director of the Center for Clinical Standards and Quality (CCSQ); and Elizabeth Fowler, PhD, JD, deputy administrator and director of the Center for Medicare and Medicaid Innovation.

Growing ACOs

There are three aspects to growth in accountable care in Medicare, Seshamani said.

Medicare staff have been engaging with ACO leaders to understand barriers to entry and retention, and where there could be opportunities to bring more people in, and changing policies to reflect those. One example is “expanding attribution to really reflect where health care is, that it doesn’t have to be a physician. It could be a nurse practitioner, physician assistant, where attribution can happen,” and many other changes along those lines, Seshamani said.

Another aspect is partnering with the Medicare innovation center to scale their ideas into the entire system. An example is using advance investment payments in the Medicare Shared Savings Program (MSSP) to ACOs in underserved areas to use accountable care methods and better serve patient populations, she said.

A third aspect is changing the foundation of Medicare, “enabling people to get the muscle memory of population health and how to change the way that we care for people.” For example, community health workers, care navigation, caregiver training are all payble now for the first time, Seshamani said. The continuum from the Medicare Physician Fee Schedule to the MSSP to innovation center models are working in alignment to drive toward the 2030 goal, she said.

National Quality Strategy

In 2022, Medicare released its National Quality Strategy with a priority area of outcomes and alignment, Hughes said.

“And I think for all of us, as we look across our various programs and our policies, there's tremendous variability, which makes it difficult for us in our end to understand the performance, the trends, what's happening, what are the issues,” Hughes said. On the provider side, in terms of burden, health care providers don’t know until if patients have traditional Medicare or Medicare Advantage until the patient comes in the door, she said.

For CCSQ, the staff consider how to make sure the quality measures that are used, are the same across programs, Hughes said. She referred to the new report “Quality in Motion: Acting on the CMS National Quality Strategy,” published this week to update on progress on the 2022 CMS National Quality Strategy.

Working together

The innovation center policies and MSSP will not reach the 2030 goal on their own, but working together can grow accountable care, Fowler said. They have a goal to bring more primary care practices in and provide opportunities for providers to take on more an do more, she said.

The ACO Primary Care Flex Model, scheduled to begin in 2025, will offer opportunities to test innovations for low-revenue ACOs, and there will be opportunities across the board, Fowler said. She also cited the AHEAD Model, for the All-Payer Health Equity Approaches and Development, and the Making Care Primary Model, scheduled to launch July 1 this year.

“So, I think there's a lot in the pipeline that hopefully will become more visible over the coming weeks,” she said.

Coming next

Seshamani noted the three shared common themes. The Medicare leadership has heard providers face at least three challenges, including the confusion of all the quality metrics and the burdens those create, so the Medicare leaders want to align those.

Another challenge is cash flow – providers who want to engage in accountable care models may not have the up-front money to invest in infrastructure to be successful. Paying for community health workers care navigation up front helps with that cash flow, Seshamani said.

A third challenge is integrating the new methods because “‘this is not how I learned to practice medicine when I was going through training’ and, you know, ‘I don’t know what to do with a community health worker,’” Seshamani said. The Medicare leaders want to bring those into the chassis of the Medicare program.

The three leaders can’t do it alone, so they want to hear from the ACO leaders about sharing best practices, for example, on how to partner with a community-based organization, she said.

“I think those are kind of three of the issues that we have heard and opportunities to further growth in caring for people in a more holistic way,” Seshamani said.

Care after REACH

The Medicare ACO Realizing Equity, Access, and Community Health (REACH) is a five-year value-based payment model. Gaus asked for an assurance that participants in the Medicare ACO REACH would have a home that is akin to the current characteristics of REACH. The situation is complicated and the Medicare leaders are pondering a transition to MSSP or a different model, which would be difficult, Fowler said.

“We're weighing all of these factors as we consider what comes next, but we're very much aware that the REACH community is looking for some certainty and looking for some signal and so we're hoping to be able to provide some of that, but I think you'll hopefully see more from us soon,” she said.

‘Elephant in the room’

Gaus asked about “the elephant in the room,” CMS and other federal regulators and lawmakers investigating possibly fraudulent billing for billions of dollars in catheters. The issue has prompted concern in Washington and Gaus asked if CMS is going to come up with a solution to mitigate losses to NAACOs members, and when.

Seshamani did not specify a dollar amount or schedule, but noted ACOs are an incredible source of information and opportunity to understand where there might be anomalous billing going on. CMS reminds ACO participants that they can contact CMS’ Center for Program Integrity and ACOs must have compliance plans, she said.

Fowler said it is a testament of success that CMS and ACO participants have more and better data and CMS is using it to root out issues.

“I think we anticipate being able to share and approach for anomalous billing related to catheters in the coming weeks,” she said.