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Over the last three years, under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) has been advancing innovative payment and service delivery models to help move our health care system from one that pays for volume to one that rewards providers for keeping patients healthy, improving health outcomes and lowering costs. A critical feature of value-based care is organizations taking on downside financial risk and accountability for the cost and quality of care their patients receive.
CMS’ Medicare Shared Savings Program is our largest value-based payment program in fee-for-service Medicare for “Accountable Care Organizations” or ACOs. ACOs are groups of health care providers that voluntarily agree to be held accountable for the quality, cost, and experience of care for a population of fee-for-service Medicare beneficiaries.
After six years of operating the Medicare Shared Savings Program, in December 2018 the Trump Administration redesigned the program, issuing the “Pathways to Success” final rule. The rule established new participation options and incentives to put ACOs on a quicker path to taking on real risk. The new participation options adopted under Pathways to Success require accountability for spending increases, generally after two years for new ACOs, and close evaluation of the quality of care provided. They also provide an option for new “low-revenue” ACOs, which are generally run by physician practices rather than hospitals, to elect an additional year before taking on “downside” risk for cost increases, since data showed that physician-led ACOs performed better than hospital-led ACOs.
