CMS announces MIPS COVID-19 Clinical Trials improvement activity

The Centers for Medicare and Medicaid Services (CMS) has made several announcements related to healthcare during the COVID-19 pandemic. The measures are designed to aid independent physicians and other providers who have begun seeing patients using telehealth options and who are making additional adjustments to cope with the outbreak. On April 20, CMS announced an incentive for clinicians to assist with research that will help monitor the spread of the virus and will aid in the search for a solution to the outbreak.

If you participate in the Merit-based Incentive Payment System (MIPS), the performance-based track of the Quality Payment Program (QPP), you can now earn credit when you, your physician’s assistant, your nurse practitioners, or other clinicians on your team participate in a clinical trial and report clinical information on COVID-19. By participating and attesting to the new COVID-19 Clinical Trials improvement activity, you will provide vital data that will help drive improvement in patient care and develop best practices to manage the spread of the virus.

In making the announcement, CMS Administrator Seema Verna said, “CMS is supporting efforts of researchers to obtain solid, actionable data to accelerate the development of new treatments and our understanding of the coronavirus.  Today’s action encourages clinicians to report data that will help us monitor the spread of the virus, find innovative medical solutions, and unleash scientific discovery as we seek to overcome this terrible disease.”

Participating in a clinical trial carries a high weight from a scoring perspective. When you report your activity, you will automatically earn half of the total credit needed to earn a maximum score in the MIPS improvement activities performance category, which counts as 15 percent of the MIPS final score.

Need help dealing with the economic effects of COVID-19? Check out Elation’s Financial Guide.

To receive this credit for the new MIPS COVID-19 Clinical Trials improvement activity, you will need to attest that you are participating in a COVID-19 clinical trial using a drug or biological product to treat a patient with a COVID-19 infection. You will then report your findings through a clinical data repository or clinical data registry for the duration of the study.

There is flexibility in the type of clinical trial that you choose to participate in, including the traditional double-blind placebo-controlled trial to an adaptive or pragmatic design that flexes to workflow and clinical practice. In its announcement, CMS also provided information on a database of privately and publicly funded clinical studies currently being conducted on coronavirus.

Examples of clinical trials include those conducted by the National Institute of Health (NIH). You might also choose to report through a clinical data repository such as Oracle’s COVID-19 Therapeutic Learning System. Oracle has developed and donated a system to the U.S. government that allows clinicians and patients to record the effectiveness of promising COVID-19 drug therapies at no cost.

As a physician on the front line of providing care to patients infected with COVID-19, you can contribute significantly to scientific research and evidence to fight the Coronavirus Disease 2019 (COVID-19) pandemic. Participation in these clinical trials will lead to improvements in care delivery and the ability to treat COVID-19 patients and will enable you to earn valuable MIPS credit for your practice.

Chris Anderson
May 11, 2020

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CMS Issues Recommendations to Re-Open practices in Areas with Low Incidence of COVID-19

As the COVID-19 situation begins to stabilize in many locations, the Centers for Medicare & Medicaid Services (CMS) has issued guidance on providing essential non-COVID-19 care to patients in certain locations. The announcement was made in coordination with the federal plan for Opening Up America Again. The CMS recommendations will serve as a guide to independent practices who may be able to re-open their practices in areas with a low incidence of COVID-19.

On March 18, CMS announced that all elective surgeries, non-essential medical, surgical, and dental procedures should be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak. In making the most recent announcement, CMS Administrator Seema Verma said:

Today, some areas of the country are experiencing fewer cases and lower incidence of the virus, necessitating a more tailored and flexible approach. Every state and local official will need to assess the situation on the ground to determine the best course forward, but these guidelines provide a gradual process for restarting non-COVID-19 essential care while keeping patients safe.

The new CMS recommendations for providing essential care to patients without symptoms of COVID-19 are specifically targeted to communities that are in Phase 1 of the Guidelines for Opening Up America Again with low incidence or relatively low and stable incidence of COVID-19 cases.

In making the announcement, CMS emphasized the importance of restarting care that is currently being postponed, “such as certain procedural care (surgeries and procedures), chronic disease care, and, ultimately, preventive care.” The organization recognized that there are a number of patients who continue to have ongoing healthcare needs that have been deferred during COVID-19.

Independent practices located in states or regions that have passed the Gating Criteria regarding symptoms, cases, and hospitals that were announced on April 16, they may proceed to Phase I. Even so, CMS is strongly encouraging the maximum use of telehealth where appropriate.

The Gating Criteria includes:

  • Symptoms: Downward trajectory of influenza-like illnesses reported within a 14-day period and downward trajectory of COVID-like syndromic cases reported within a 14-day period.
  • Cases: Downward trajectory of documented cases within a 14-day period or downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests)
  • Hospitals: Treat all patients without crisis care and robust testing program in place for at-risk healthcare workers, including emerging antibody testing.

CMS states that non-COVID-19 care should be offered to patients as clinically appropriate and in an area that has the necessary resources to quickly respond to a surge in COVID-19 cases if necessary. The decision regarding whether to provide non-COVID-19 care should be consistent with public health information and in collaboration with state public health authorities.

All aspects of non-COVID-19 care should be considered, including:

  • Adequate facilities, workforce, testing, and supplies
  • Adequate workforce across phases of care (such as availability of clinicians, nurses, anesthesia, pharmacy, imaging, pathology support, and post-acute care).

Independent physicians within these areas should continually evaluate whether their region remains a low risk of incidence and should be prepared to cease non-essential procedures if there is a surge in COVID-19 cases.

Janie Feldsher
May 8, 2020

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HHS Care Act additional allocations

The COVID-19 pandemic has affected healthcare providers in many ways. Some physicians are stressed with how to continue providing quality care to their patients. Healthcare delivery has shifted to telehealth in many locations. Independent physicians are feeling the financial strain of the outbreak. To help alleviate some of the distress placed on providers by the coronavirus outbreak, relief funds have been appropriated to hospitals and other healthcare providers under the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

The CARES Act was initially signed into law on March 27, 2020 and included $100 billion for the Provider Relief Fund. The first round of funding, $30 billion, was distributed in early and mid-April and was “proportionate to providers’ share of Medicare fee-for-service reimbursements in 2019,” according to the US Department of Health & Human Services (HHS).

HHS has announced that it “has begun distributing the remaining $20 billion of the $50 billion general distribution to Medicare providers to augment providers’ allocations so that the whole $50 billion general distribution is allocated proportional to providers’ share of 2018 net patient revenue.”

On April 24, a portion of providers were automatically sent an advance payment based off the revenue data they submitted in CMS cost reports. Providers without adequate cost report data on file will need to submit their revenue information to the General Distribution Portal for additional general distribution funds.

In addition, the COVID-19 Uninsured Program Portal, which allows healthcare providers who have conducted COVID-19 testing or provided treatment for uninsured COVID-19 individuals on or after February 4, 2020 to request claims reimbursement, is now live. HHS has clarified that it “broadly views every patient as a possible case of COVID-19.” The organization has also stated that “a healthcare provider’s eligibility is not adversely affected if it ceased operations as a result of the COVID-19 pandemic, so long as the healthcare provider provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.”

The terms and conditions of receiving the relief funds include:

  • All recipients will be required to submit documents sufficient to ensure that these funds were used for healthcare-related expenses or lost revenue attributable to coronavirus.
  • Providers must agree not to seek collection of out-of-pocket payments from a presumptive or actual COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

Independent practices are being significantly impacted by the coronavirus. The Medical Group Management Association (MGMA) conducted a survey in early April and received 724 applicable responses, approximately 75% of which were part of independent medical practices and employed less than 50 full-time-equivalent (FTE) physicians.

The survey revealed that 97% of those practices have experienced a negative financial impact directly or indirectly related to COVID-19. The survey also found that, on average, practices have experienced a 55% decrease in revenue and 60% decrease in patient volume since the beginning of the COVID-19 crisis.

Elation Health is dedicated to supporting independent physicians throughout the coronavirus outbreak. We have developed a COVID-19 Resource Center that includes information on Financial Resources for your practice, as we are committed to ensuring your success in dealing with the economic effects of COVID-19.

Chris Anderson
May 4, 2020

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CMS approves $34 billion for providers

In an ongoing effort to provide financial relief for healthcare providers, the Centers for Medicare & Medicaid Services (CMS) has expanded its Accelerated and Advance Payment Program, opening up $34 billion for a broader group of physicians, hospitals, and suppliers. The payment program, expanded in response to the 2019 Novel Coronavirus (COVID-19) pandemic, has been expanded for the duration of the public health emergency.

The new streamlined process has reduced processing times for requests for accelerated or advance payments. The timeframe is expected to be between four and six days during the COVID-19 pandemic, down from the normal timeframe of three to four weeks. CMS has already approved over 17,000 requests.

Accelerated or advance payments are provided during the period of the public health emergency to any Medicare provider or supplier who submits a request to the appropriate Medicare Administrative Contractor (MAC) and who meets the required clarifications. Part A providers and Part B suppliers, including doctors, non-physician practitioners, and durable medical equipment (DME) suppliers are eligible. CMS has indicated that, while most of these providers and suppliers can receive three months of their Medicare reimbursements, certain providers can receive up to six months.

Elation Health has COVID-19 updates and resources you need for your independent practice.

To qualify for advance or accelerated payments the provider or supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form
  • Not be in bankruptcy
  • Not be under active medical review or program integrity investigation
  • Not have any outstanding delinquent Medicare overpayments.

CMS advance and accelerate payments are not a part of the funding available as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. CARES Act funding of $100 billion does not have to be repaid. The advance and accelerated payments available through CMS are a loan that providers must pay back. CMS will begin to apply claims payments to offset the accelerated and advance payments 120 days after they are disbursed.

CMS clarifies that the provider/supplier can continue to submit claims as usual after the issuance of the accelerated or advance payment; however, recoupment will not begin for 120 days. Providers will receive full payments for their claims during the 120-day delay period. At the end of the 120-day period, the recoupment process will begin and every claim submitted by the provider will be offset from the new claims to repay the accelerated/advanced payment. Instead of receiving payment for newly submitted claims, the provider’s outstanding accelerated/advance payment balance is reduced by the claim payment amount. The process will be automatic.

The Department of Health and Human Services (HHS) will be providing additional information on how healthcare providers and suppliers can access CARES Act funds in the coming weeks. The CARES Act provides $100 billion in relief funds to hospitals and other healthcare providers on the front lines of the coronavirus response. This funding will be used to support healthcare-related expenses or lost revenue attributable to COVID-19.

Janie Feldsher
April 21, 2020

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Understanding the CARES Act and what it means for independent practices

The Coronavirus Aid, Relief, and Economic Security (CARES) Act was officially signed into law on March 27, 2020. The CARES Act offers financial relief for many individuals and small businesses. There are also a number of provisions in the Act that are beneficial to healthcare professionals. Independent physicians should be aware of several immediate key takeaways from the CARES Act.

The Centers for Medicare & Medicaid Services (CMS) is increasingly recognizing the critical need for and benefits of telehealth, noting that “with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care, and keep vulnerable beneficiaries and beneficiaries with mild symptoms in their homes while maintaining access to the care they need.”

The CARES Act opens up additional opportunities for independent physicians to take advantage of telehealth for their patients. Providers no longer need a pre-existing relationship with a patient to provide telehealth services and Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are now sites of care for telehealth.

The American Medical Association (AMA) has outlined the provisions of the CARES Act that expand telehealth:

  • Health Resources and Services Administration (HRSA) grant programs that promote the use of telehealth technologies for health care delivery, education, and health information services are included with a specific emphasis on rural health centers. The use of telehealth in rural or medically underserved communities offers providers more flexibility to screen, monitor care, or treat their patients with, or at risk of contracting, COVID-19 while avoiding exposure to others.
  • A high deductible health plan may include telehealth services for free and continue to be characterized as a high deductible health plan.
  • The HHS Secretary has the authority to waive requirements during a national emergency and has allowed for increased Medicare telehealth flexibility and uses during COVID-19 pandemic.
  • The Secretary allows for enhanced use of telehealth in Medicare for federally qualified health centers (FQHCs) and rural health clinics during the emergency period. Payment for these services can be determined by the Secretary or can be comparable to the telehealth rates currently paid for similar services.
  • There is also a temporary waiver of the requirement for face-to-face visits between home dialysis patients and physicians. (Section 3705) Telehealth may be used to conduct face-to-face encounters prior to recertification of eligibility for hospice care.

To provide financial relief for healthcare providers, the CARES Act boosts Medicare payments by 2 percent through the end of 2020 for physicians, hospitals, nursing homes, and home health. In addition, the Act requires all private insurance plans, Medicare, and Medicaid to cover COVID-19 treatments and vaccine and makes all coronavirus tests free.

Given the critical need for healthcare providers during the COVID-19 pandemic, the CARES Act also addresses the issue of liability for volunteers who offer their help during the emergency response. According to the AMA fact sheet, “physicians who provide volunteer medical services during the public health emergency related to COVID-19 have liability protections. These new protections are in addition to those provided by the Volunteer Protection Act of 1997. Volunteers are defined as those who are not paid for their services.”

Janie Feldsher
April 17, 2020

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MIPS deadline extended in response to COVID-19

The Centers for Medicare & Medicaid Services (CMS) has announced a deadline extension, along with several exceptions from reporting requirements for primary care providers and other healthcare professionals participating in Medicare quality reporting programs. The changes affect upcoming measure reporting and data submission for those programs. CMS is taking these steps in an effort to provide relief for providers during the current COVID-19 pandemic.

CMS states that it is taking actions to assist the “clinicians, providers, and facilities participating in Medicare quality reporting programs including the 1.2 million clinicians in the Quality Payment Program and on the front lines of America’s fight against the 2019 Novel Coronavirus (COVID-19).” CMS Administrator Seema Verma says, “In granting these exceptions and extensions, CMS is supporting clinicians fighting Coronavirus on the front lines.”

The deadline for 2019 data submission for the Quality Payment Program (QPP) – Merit-based Incentive Payment System (MIPS) has been extended from March 31, 2020 to April 30, 2020. In addition, MIPS eligible providers who do not submit MIPS data by the new deadline will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.

Primary care providers are included in the MIPS option of the QPP if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.

MIPS performance is measured through the data clinicians report in four areas:

 Learn more about the importance of certified EHRs for participating in MIPS.

The CMS announcement also stated that:

  • It is evaluating options for providing relief around participation and data submission for 2020.
  • Data submission will be optional for those programs with data submission deadlines in April and May 2020, based on the facility’s choice to report.
  • No data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs.

CMS recognizes the burden placed on providers who are responding to the COVID-19 pandemic, in having to also focus on data collection and reporting for MIPS. The agency also acknowledges that the numbers may be somewhat skewed during a time of national emergency, particularly in regard to cost, readmissions, and patient experience. Quality measure data collection and reporting during the pandemic may not be reflective of the provider’s true performance and CMS seeks to hold healthcare organizations harmless for not submitting data during this time.

Going forward, CMS has indicated it will continue to monitor the COVID-19 situation. Healthcare providers must focus on caring for patients first and foremost so additional options will be assessed for offering additional relief to primary care providers and their staff during the emergency period.

Janie Feldsher
March 30, 2020

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Understanding Bernie Sanders’ Medicare for All proposal

Senator Bernie Sanders (D-Vermont) is a candidate in the 2020 presidential election and a proponent of a one-payer healthcare program. Specifically, Sanders introduced a bill in the Senate and includes a plan in his campaign that has been labeled Medicare for All. Although credited with the term and with the initiative, it was actually Republican Senator Jacob Javits who proposed expanding Medicare to cover all Americans in 1970 through a program he called “Medicare for all.”

The program Sanders has proposed is somewhat different from that submitted by Javits and actually expands the concept of Medicare as it exists today. The senator cites the fact that medical bills are the primary cause of bankruptcy for Americans and that people need a healthcare program that will cover more, if not all, of their expenses while ensuring they receive the highest quality care. Sanders states that “We should be spending money on doctors, nurses, mental health specialists, dentists, and other professionals who provide services to people and improve their lives.”

The Sanders platform states that the way to reduce costs and to refocus payments, away from private insurance and giant pharmaceutical companies, is by  “Joining every other major country on Earth and guaranteeing health care to all people as a right, not a privilege, through a Medicare-for-all, single-payer program.” His plan would virtually eliminate private insurance and replace it with the expanded government-sponsored program.

The Washington Times reports that the Medicare for All program proposed by Sanders “would cover all U.S. residents, including illegal immigrants. It would pay for doctor and hospital visits, prescription drugs, dental and vision services, and long-term care. Private insurance would be allowed, but only as a supplement.” Many of those services, including dental and vision, are not now covered under basic Medicare plans.

Medicare for All, as proposed by Sanders, would also focus on the affordability of prescription drugs specifically. His plan would:

  • Allow Medicare to negotiate with the big drug companies to lower prescription drug prices with the Medicare Drug Price Negotiation Act.
  • Allow patients, pharmacists, and wholesalers to buy low-cost prescription drugs from Canada and other industrialized countries with the Affordable and Safe Prescription Drug Importation Act.
  • Cut prescription drug prices in half, with the Prescription Drug Price Relief Act, by pegging prices to the median drug price in five major countries: Canada, the United Kingdom, France, Germany, and Japan.

Janie Feldsher
March 2, 2020

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Is biometric data a HIPAA risk?

Biometrics are gathered to digitally identify individuals, based on unique physical characteristics. Biometrics include fingerprints, facial features, voice cadence, and other identifiers. The US Department of Homeland Security uses biometrics primarily for immigration purposes, vetting and credentialing, detecting illegal entry attempts, and verifying visa applications. In healthcare, biometrics are used to identify patients and to ensure that employees have access only to the information they need to know.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. In 2009, as part of the American Recovery and Reinvestment Act (ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law. The HITECH Act addresses the privacy and security concerns associated with the electronic transmission of protected health information.

As the use of biometrics becomes more prevalent in healthcare, providers must exercise care in regard to adhering to the regulations of HIPAA and the HITECH Act. Biometrics are in the category of protected health information (PHI) and as such, healthcare providers must ensure that appropriate safeguards are put in place to protect the confidentiality and integrity of the information.

How does Elation Health help safeguard your patient’s data?

Illinois was the first state to recognize the importance of protecting data gathered through biometrics. In 2008, the state passed the Biometric Information Privacy Act (BIPA), which applies to healthcare, hospitality, retail, and any employer who uses fingerprint technology. Many businesses use employees’ fingerprints, for example, for timekeeping purposes.

BIPA requires healthcare providers to, in most instances:

  • Put into place adequate technical, administrative, and physical safeguards
  • Have a written policy, schedule, and guidelines for the data’s collection, retention, and destruction
  • Provide advance disclosure and a written release from the patient
  • Adhere to restrictions regarding disseminating the biometric information.

Following the example set in Illinois, five other states – Texas, Washington, California, New York, and Arkansas – have passed similar biometric statutes. The California Consumer Privacy Act (CCPA), which will go into effect in 2020, defines biometric data as “physiological, biological or behavioral characteristics, including … DNA[,] that can be used … to establish individual identity,” which includes “sleep, health, or exercise data that contain identifying information.”

Given the definitions of HIPAA, the HITECH Act, and biometrics as they are used in healthcare, there is a risk involved in collecting and maintaining this data. As with all PHI, steps must be taken to ensure the security and integrity of biometrics when used in a healthcare setting to comply with federal regulations and to provide patients with appropriate data safeguards.

Janie Feldsher
February 19, 2020

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History of CMS primary care initiative

Many factors went into the development of the Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative, including a concern for patient healthcare outcomes, a need to reduce healthcare costs, and a focus on reducing hospitalizations. Based on the previous Comprehensive Primary Care (CPC) models, the new initiative includes five models developed by the Center for Medicare and Medicaid Innovation (CMMI) with input from physicians and organizations such as the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA).

CPC models were launched in October 2012 as a “a four-year multi-payer initiative designed to strengthen primary care.” CPC was the foundation of a five-year initiative, Comprehensive Primary Care Plus (CPC+), “a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.” Each of these initiatives offered various levels of physician participation, based on different payment models. The original CPC initiative concluded in 2016.

CPC+ was launched in January 2017, integrating “lessons learned from CPC, including insights on practice readiness, the progression of care delivery redesign, actionable performance-based incentives, necessary health information technology, and claims data sharing with practices.” CPC+ included three payment elements: Care Management Fee (CMF); Performance-Based Incentive Payment; and Payment under the Medicare Physician Fee Schedule, with two track options.

The latest initiatives were developed by CMMI with input from stakeholders and a focus on the need to improve primary care outcomes that will reduce hospitalization rates for Medicare recipients. When announcing the CMS Primary Cares Initiative, CMS Administrator Seema Verma referenced the financial state of what is commonly known as Medicare Part A. Essentially, the Social Security Board of Trustees reported “that the Hospital Insurance (HI) Trust Fund portion—otherwise known as Medicare Part A—will be depleted in 2026, the same year projected in last year’s report. Revenues will be enough to pay 89% of HI costs.”

In regard to the CMS Primary Cares Initiative, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar stated that “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision.” He added, “these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.”

Janie Feldsher
January 21, 2020

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Gauging ACO success in 2019

The number of ACO contracts has decreased slightly, but the number of individuals covered by those ACOs has increased from 2018 to 2019. The Centers for Medicare & Medicaid Services (CMS) recently released data on Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) for Performance Year 2019 that show some changes in provider participation as of July 1, 2019. Experts writing for Health Affairs analyzed the results of the report, gauging the level of ACO success during the reporting period.

MSSP “facilitates coordination among providers to improve the quality of care for Medicare fee-for-service beneficiaries while reducing the growth in health care costs. Eligible providers, hospitals, and suppliers may apply to participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).” In addition, CMS has created a new ACO program, Pathways to Success, which may also have impacted the success of ACOs in 2019.

The Health Affairs analysts state that there has been an increase in the number of physician-led ACOs “and they have moved to downside risk at a slightly higher rate than ACOs with hospitals.” The total number of ACOs has decreased while the number of lives impacted has increased during the performance year. Of the 995 ACOs currently active, 425 (43 percent) are physician-led, compared to 274 hospital-led and 294 jointly led.

Previous estimates speculated that about half of ACOs would exit MSSP, the largest ACO program, with the rollout of the Pathways to Success program. However, in reality only a modest number left and 41 ACOs joined the program in July 2019. Higher dropout rates were noted for physician-led ACOs than for hospital-led and large ACOs.

Health Affairs also reports that “so far this year in 2019, there was a modest decrease in the proportion of downside risk contacts by small organizations, and conversely there was a modest increase in proportion of downside risk contacts by large organizations.” The analysts stated that “The acceleration of ACOs accepting downside risk beginning in 2019 could represent the MSSP policy changes taking effect and deterring smaller organizations from joining or staying based on mandatory downside risk.”

Tyler Comstock
December 9, 2019

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