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Joining an ACO Key to Success Under MACRA, Report Finds


The report finds that being part of an ACO allows clinicians to be rated as a group for a key measure to determine Medicare reimbursement.

Joining an accountable care organization (ACO) could help clinicians raise key Medicare performance scores up to 30%, which boosts their chances of higher reimbursement relative to competitors, according to a new report from Caravan Health.

The report, by Lynn Barr MPH, CEO of Caravan Health, and LeeAnn Hastings, JD, MPH, a compliance officer for 23 ACOs under the Medicare Shared Savings Program (MSSP), compared what payments will look like for clinicians inside and outside ACOs under the Medicare Access and CHIP Reauthorization Act (MACRA, passed in 2015 to push healthcare toward value-based payment.

Under MACRA, performance data reported from 2017 will be used to calculate payments in 2018. CMS has worked to ease the transition to value-based payment, allowing clinicians to select how quickly they want to take on the associated risk. In fact, reporting a small amount of data for 2017 can help clinicians avoid penalties.

The report centers on the Merit-Based Incentive Payment System, or MIPS, which is expected to be the reimbursement path that most clinicians use in the early years of MACRA. Those practices that are further along in working with value-based payments may instead pursue reimbursement under the advanced alternative payment model (APM) track.

However, MACRA not only pushes clinicians further away from fee-for-service, but also calls for clinicians to be rated against one another. For those who seek higher payments, this factor further separates those taking part in ACOs from those who are not, the report finds, since clinicians in ACOs will be rated together for 1 key measure.

In a policy brief, “Impact of MIPS Payments for all Eligible Clinicians,” Barr and Hastings found that taking part in MSSP will boost MIPS performance, particularly the ability of the clinicians to qualify for “exceptional performance” bonuses, which will only be offered during the first 5 years of the program.

The key, the brief notes, is that clinicians taking part in ACOs will not be scored individually on “resource utilization.” All Track 1 ACO participants—those who do not meet criteria for advanced APMS—will be rated in as a group with the rest of their ACO. This accounts for 30% of the performance score. So, the brief finds, “these participants can more easily achieve high scores compared to other MIPS participants, increasing the likelihood of avoiding MIPS penalties and earning the exceptional performance bonus.”

“Small practices should consider joining an ACO to avoid penalties for generally lower scores due to lack of infrastructure, and providers in rural areas may want to join ACOs to

avoid MIPS penalties due to their higher cost structures,” Barr said in a statement. “Community hospitals can earn high bonuses and support their community physicians, particularly specialists, by enrolling them in their ACO, protecting their incomes and reducing their administrative burden.”

To help physicians and health systems brace for the change, The American Journal of Managed Care® created the ACO & Emerging Healthcare Delivery Coalition®, which hosts 2 meetings each year for those involved in quality care initiatives. Attendees can share best practices and hear from experts about new payment models. The next meeting of the ACO Coalition will be May 4-5, 2017, in Scottsdale, Arizona.

Speakers at this meeting, themed “Prepare for Impact,” will give special attention to how the change of administration will affect the transition to value-based care. Speakers include conservative commentator Avik Roy; University of Southern California health economist Darius Lakdawalla, PhD; and former CMS official Sachin Jain, MD, MBA, FACP, now the CEO of CareMore.

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