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From Health Law Daily, April 25, 2013

CMS to maintain existing plan for Pioneer ACO payments for 2013

By Paul Clark

CMS has informed health care organizations participating in the Pioneer Accountable Care Organization (ACO) Model that it will not change the way it determines pay-for-performance benchmarks for quality measures in 2013. The 32 Pioneer ACOs sent a letter to CMS in February expressing concern about how the ACOs payments would be determined this year.

Pioneer ACOs. First, some background. As part of the Patient Protection and Affordable Care Act (P.L. 111-148) (PPACA) Congress created the Medicare Shared Savings Program to encourage groups of doctors, hospitals, and other health care providers to organize into ACOs to provide coordinated health care to Medicare beneficiaries. The idea behind ACOs is that a group of providers could design more innovative and efficient ways of providing health care than traditional fee-for-service Medicare, and these providers could be rewarded for the quality of the health care they provide, and not the quantity of services. If ACOs provide care that costs less than what traditional Medicare would pay, the ACO will share in the savings.

PPACA also established the Pioneer ACO Model for organizations who already had experience offering coordinated, patient-centered care, and operating in ACO-like arrangements. The idea behind the Pioneer ACOs was that these organizations could move quicker than newer organizations to provide coordinated care to Medicare beneficiaries. CMS created a list of 33 quality measures for which participating ACOs would have to provide data and also meet specified benchmarks in order to receive payments.

CMS signed agreements with 32 health care organizations spread around the country to participate in the Pioneer ACO program. The program runs from January 2012 until the end of 2014. In 2012, Pioneers received payments just for reporting data on the 33 quality measures. Starting in 2013, Pioneers will be paid based on the actual care they provide. And how this is measured is what has Pioneers concerned.

February letter. In February, the Pioneer ACOs sent a letter to CMS expressing concern that at least 19 of the quality measures did not have sufficient data on which to base “empirical benchmarks,” basically flat percentages of different types of care that the ACOs would have to show they provided. The Pioneers also noted that “the proposed benchmarks are higher than standards set in commercial contracts and Medicaid.” The Pioneers suggested “that using the ACO database to determine best in class performance for the [quality] measures will help set and scale percentiles accordingly.” The Pioneers also expressed concern with the use of data from Medicare Advantage plans in setting benchmarks. “We believe there are fundamental differences between the experience of non-managed and managed populations that warrant consideration when establishing pay-related benchmarks,” according to the letter.

CMS letter. In an April 23, 2013, letter to all Pioneer ACOs, CMS said it will continue to use “actual Medicare fee-for-service (FFS) and Medicare Advantage (MA) performance data in establishing ACO quality performance benchmarks.” CMS noted that it was using flat percentage benchmarks in part because of lack of national data. CMS added, however, that “over 200 organizations recently completed submitting data through the Physician Quality Reporting System (PQRS) and ACO Group Practice Reporting Option (GPRO) reporting processes,” and that this new data would also be used to set benchmarks for 2013.

CMS also noted that it will soon issue proposals on how it will include 2012 data submitted by ACOs to establish benchmarks for the shared savings program in 2014; these benchmarks will also apply to Pioneer ACOs in 2014.

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