CMS New ACO Pathways to Success Program
The CMS on Dec. 21, 2018 finalized its revamping of the Medicare Shared Savings Program—now called Pathways to Success. The new Pathways to Success program, which becomes effective July 1, 2019, requires Accountable Care Organizations (ACOs) to assume downside risk more quickly.
The CMS made the decision in large part to address the significant number of risk-averse ACOs currently in the program. 82% of ACO are currently in Track 1 which provides an upside contract where CMS shares performance based savings but ACOs are not responsible for any downside financial losses.
Under the revamped program, ACOs can choose to participate in either the basic or enhanced tracks. The basic track, which has a five-year performance period, only allows incumbent ACOs to be in a one-sided risk contract if they have no prior experience with downside risk and this option is only good for one year. In subsequent years of the basic track, ACOs will be forced to enter contracts with “progressively higher risk”. The enhanced track is based on Track 3 of the current MSSP, which is the most advanced track with the most downside risk. The CMS expects all ACOs to ultimately progress to the enhanced track.
Comparison Basic vs. Enhanced Tracks
Basic Track Glide Path | |||||
Level A & Level B (one-sided model) | Level C (risk/reward) | Level D (risk/reward) | Level E (risk/reward) | Enhanced Track | |
Shared Savings (once MSR met or exceeded) | 1st dollar savings at a rate up to 40% based on quality performance; not to exceed 10% of updated benchmark |
1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark |
1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark |
1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark |
No change. 1st dollar savings at a rate of up to 75% based on quality performance, not to exceed 20% of updated benchmark |
Shared Losses (once MLR met or exceeded) | N/A | 1st dollar losses at a rate of 30%, not to exceed 2% of ACO participant revenue capped at 1% of updated benchmark | 1st dollar losses at a rate of 30%, not to exceed 4% of ACO participant revenue capped at 2% of updated benchmark |
1st dollar losses at a rate of 30%, not to exceed the percentage of revenue specified in the revenue-based nominal amount standard under the Quality Payment Program capped at 1 percentage point higher than the benchmark nominal risk amount (e.g., 8% of ACO participant revenue in 2019 – 2020, capped at 4% of updated benchmark) |
No change. 1st dollar losses at a rate of 1 minus final sharing rate, with minimum shared loss rate of 40% and maximum of 75%, not to exceed 15% of updated benchmark |
Annual choice of beneficiary assignment methodology? |
Yes | Yes | Yes | Yes | Yes |
Annual election to enter higher risk? |
Yes, but new low revenue ACOs may elect an additional year under Level B if they commit to completing the remainder of their agreement under Level E. |
Yes |
No; ACO will automatically transition to Level E at the start of the next performance year, except for July 1, |
No; maximum level of risk/reward under the BASIC track
|
No; highest level of risk/reward |
Advanced APM status under the Quality Payment Program? |
No | No | No | Yes | Yes |
Beneficiary Incentive Program
|
No |
Yes, ACOs may establish an approved program starting July 1, 2019, or in subsequent years |
Yes, ACOs may establish an approved program starting July 1, 2019, or in subsequent years |
Yes, ACOs may establish an approved program starting July 1, 2019, or in subsequent years |
Yes, ACOs may establish an approved program starting July 1, 2019, or in subsequent years |
Expanded Telehealth Services |
N/A |
Yes, available to ACOs electing prospective assignment methodology for performance year |
Yes, available to ACOs electing prospective assignment methodology for performance year |
Yes, available to ACOs electing prospective assignment methodology for performance year |
Yes, available to ACOs electing |
3-Day SNF Rule Waiver |
N/A |
Yes, ACOs may apply to start on July 1, 2019, and in subsequent years |
Yes, ACOs may apply to start on July 1, 2019, and in subsequent years |
Yes, ACOs may apply to start on July 1, 2019, and in subsequent years |
Yes, ACOs may apply to start on July 1, 2019, and in subsequent years |
CMS Medicare Shared Savings Program: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ssp-aco-participation-options.pdf