CMS Finalizes “Pathways to Success”
CMS recently made changes to Medicare’s Accountable Care Organization program by adding Pathways to Success. The program, “Pathways to Success,” is going to encourage provider participation, minimize costs, and keep healthcare quality high.
It’s going to save $2.9 billion over a ten-year period.
The new program reflects the desire to build a value system that rewards providers for giving value to patients.
The current healthcare system mostly rewards providers for a high volume of services. According to the Centers for Medicare and Medicaid Services (CMS), the change is necessary because the current American healthcare system is unsustainable.
By 2026, one of every five dollars spent in the economy will go to healthcare.
Understanding the Pathways to Success Accountable Care Organizations
Accountable Care Organizations, or ACOs, are groups of healthcare providers that take responsibility for the overall quality of care they provide, and what it costs.
ACOs have several goals: improving coordination of care among providers, providing better preventive care, improving the patient experience, and eliminating duplicative services.
When ACO providers can save money while still meeting standards for quality, they share in the cost savings. ACOs also receive waivers of certain regulatory requirements, allowing them to innovate.
Original Medicare’s ACO program has been in effect for six years, and the number of ACOs has grown steadily. In 2018 there were 649 ACOs nationwide, providing care to about 12.3 million Medicare beneficiaries.
Providers Will Now Share the Cost Risk
In the past, providers who participated in ACOs were rewarded for cost savings, but most of them didn’t suffer any consequences if their costs increased. So even with the incentives, the MSSP has seen increases in spending that cost the government and taxpayers money.
CMS discovers that the ACOs being held accountable for costs do better than those that aren’t held accountable.
The pathways for success program has strict rules about the time an ACO can stay without being held accountable for spending. In the past, providers could be in the program for six years without spending accountability.
Now, ACOs led by physicians have a maximum of three years; other new ACOs will have two years, and existing one-sided ACOs will have one year.
Encouraging Physician Groups to Form ACOs
CMS data shows that the physician-led “low revenue” ACOs have generally done a better job of controlling costs than hospital-led ACOs.
Also, CMS believes ACOs may benefit doctors who want to maintain independent medical practices instead of joining large hospital groups.
CMS hopes the new ACO rule will encourage doctors to set up ACOs, thus improving competition in the healthcare marketplace and giving patients more choice in where to receive care.
What this means for Patients
Patients of pathways for success must write that they are receiving healthcare from an ACO; then, the notice must also explain what it means to be part of the ACO.
ACOs that take on financial risk can offer patients incentive payments; beneficiaries must take care of their own health by seeing their doctor and getting follow-up care.
For more detailed information on the new ACO rules, see this CMS fact sheet.
Understanding Pathways to Success
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