Braving the New Frontier of Accountable Care Organizations
On May 17, 2011, the Center for Medicare and Medicaid Innovation, a part of the Centers for Medicare & Medicaid Services ("CMS"), announced a "Pioneer ACO Model" designed for providers that are already experienced in coordinating care for patients across care settings.
The Pioneer ACO program provides higher risks and greater rewards in the first two years of the program than those available to non-Pioneer Accountable Care Organizations ("ACOs"). Specifically, non-Pioneer ACOs can choose from two tracks that vary on risk and reward under the CMS proposed ACO regulations. Track One ACOs are those involved in a “one-sided model” that begins as a no-risk shared-savings payment system for the first two years and converts to a risk-sharing payment system in the third year. Track Two ACOs are those that are involved in a "two-sided model,” with risk-sharing (of both savings and losses) beginning in year one. Pioneer ACOs also participate in two-sided risk sharing from year one.
Generally, if any net Medicare savings exceed the minimum savings rate, the ACO can receive a portion of the additional net Medicare cost savings in excess of the minimum savings rate (the "Shared Savings"). The percentage depends on the type of ACO and amount of shared risk, as follows:
Year 1 Shared Savings
Year 2 Shared Savings
Up to 50%
Up to 52.5%
Up to 60%
Up to 65%
Up to 60%
Up to 70%
Pioneer ACOs that have met a "minimum average annual savings amount" in those first two years will then transition to a population-based payment system, which yields a per-beneficiary per month payment amount. This type of payment system is intended to replace a significant amount of the ACO's fee-for-service payments with a prospective payment.
While the potential rewards are quite high, as noted above, the risk and CMS requirements are also quite high. Pioneer ACOs will be held financially accountable for the care they provide and be expected to improve health while reducing spending. Moreover, CMS will publicly report the performance of Pioneer ACOs on its website.
CMS is looking for 30 organizations to partake in its Pioneer ACO Model program. Interested organizations are required to submit a Letter of Intent by June 10, 2011 and an application by July 18, 2011. For more information on Pioneer ACOs see CMS's Pioneer ACO Application website.
Overall, those choosing to embark on the Pioneer ACO track, like anyone exploring new frontiers, will face great risk and unknowns in order to obtain a potentially great reward.
Related ACO Articles from Foster Swift
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- CMS Finally Proposes to Waive Certain Fraud and Abuse Laws for ACOs
- Is the IRS a Friend or Foe of Accountable Care Organizations?
- Accountable Care Organization ("ACO") Analysis
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Best Lawyers® 2020
Congratulations to the attorneys of the Health Care practice group at Foster Swift Collins & Smith, PC for their inclusion in the Best Lawyers in America 2020 edition. Firm-wide, 42 lawyers were listed. Best Lawyers lists are compiled based on an exhaustive peer-review evaluation and as lawyers are not required or allowed to pay a fee to be listed; inclusion in Best Lawyers is considered a singular honor. Health Care practice group members listed in Best Lawyers are as follows:
- Gilbert M. Frimet, Southfield
- Richard C. Kraus, Lansing
- Gary J. McRay, Lansing
- Jack A. Siebers, Grand Rapids/Holland
- Jennifer B. Van Regenmorter, Holland
To see the full list of Foster Swift attorneys listed in Best Lawyers 2020, click here.