Table 1.

Important changes between the Accountable Care Organization proposed and final rules

Aspect of ACO ProgramDetailed Changes
Financial provisionsThe final rule reduces financial risk and allows for all ACOs to earn savings from the first dollar saved. CMS initially proposed a rule that only ACOs that shared financial risk in the two-sided model could share in savings from the first dollar that their ACO saved Medicare. The final rule also eliminates a 25% withhold of savings for all participants.
Application and structural changesThe final rule eliminates the initial application requirement to obtain a mandatory Antitrust Agency review and instead, provides a voluntary expedited review. The requirement to undergo an Antitrust Agency review each time an ACO adds a provider or supplier was also eliminated.
Eligible entitiesThe proposed rule listed the four groups outlined in the Affordable Care Act and critical access hospitals paid through Method II as eligible to apply as ACOs. The final rule added Federally Qualified Health Centers and Rural Health Clinics to the list of eligible entities. For all entities, established ACO beneficiaries will be assigned based on use of primary care services; thus, all entities applying must provide a list of practitioners who provide primary care services in their facilities.
Patient assignmentThe initial proposal assigned patients retrospectively based on the plurality of primary services. This approach was changed to incorporate a hybrid of preliminary prospective assignment with quarterly beneficiary identification and reconciliation of assignment at the end of each performance year based on the patient’s plurality of primary care during that year. This approach allows for the identification of beneficiaries after the initial ACO application without waiting until after 1 year of management as initially proposed. The final rule outlined not only assignment based on plurality of primary care services rendered by a primary care physician but also assignment for beneficiaries who have not had care from any primary care physician. These patients will be assigned based on plurality of primary services provided by any ACO professional (i.e., nephrologists). CMS will monitor avoidance of high-risk patients and as stated in the proposed rule, will terminate ACO agreements if this behavior is revealed.
Beneficiary data sharingIn addition to sharing limited patient data (name, date of birth, sex, and health insurance claim number) at initiation of application, the frequency of beneficiary data reports to the ACO was increased from yearly to quarterly. Established ACOs will have the opportunity to ask CMS for additional patient-specific data after receiving patient consent. The ACOs are required to notify the beneficiaries of data sharing and the opportunity to decline. If the assigned beneficiary declines data sharing with the ACO, the ACO is still responsible for their care (quality, cost, and outcomes).
Quality measuresThe initial 65 quality measures in five domains have been decreased to 33 measures in four domains. Unfortunately the only measure with significant impact on CKD management, microalbuminuria screening, was eliminated. During the first year, CMS will pay for reporting the measures, and during the second and third years of the agreement period, CMS will pay for both reporting and performance. Although declaring 50% of the primary care physicians as meaningful users of the EMR is no longer a condition for participation, the EMR remains a quality measure now weighted higher than the other measures. This change will allow practices to apply for inclusion in the ACO program while developing the EMR tools.
  • ACO, accountable care organization; CMS, Centers for Medicare and Medicaid Services; EMR, electronic medical record.