ACOs Want Deadline Extended for CMS's Pathways to Success Applications

NAACOS says its members need an additional month to examine the complex 267-page final rule, which was issued on December 21, before making critical decisions affecting participation.

Accountable care organizations are asking the federal government to push back by at least one month the application deadline for the new Pathways to Success program.

The Centers for Medicare & Medicaid Services released the bulky, 267-page final rule for Pathways to Success on December 21, and this week announced that applications to participate in the program would be due February 19.

The National Association of ACOs said that's not enough time, and they're asking CMS to give ACOs until later in March to understand the complex changes and participation options with physicians and other providers.

“There are too many difficult decisions to rush," NAACOS President and CEO Clif Gaus said in a media release. "ACOs barely have time to understand the new rules, and organizing an application is very complicated and for some it is now a high-risk decision."

The February 19 deadline applies to new ACOs, ACOs whose agreements expired at the end of 2018, and ACOs who want to end their current agreements and start under the new Pathways structure.

ACOs with three-year agreements that expire at the end of 2019 or 2020 are allowed to finish those contracts before starting in the new structure.

NAACOS said that CMS's final rule "dramatically" shortens the time ACOs have before being put at risk for repaying losses for not hitting pre-set spending targets.

The changes also lowered the financial incentive to participate in no-risk models by cutting the shared savings rate to 40%. CMS also established a distinction between so-called "high revenue" and "low revenue" ACOs, forcing high revenue ACOs into risk-bearing models faster," NAACOS said.

NAACOS had already raised concerns that some changes in the final rule would limit interest in the voluntary program and compel participating ACOs to drop out and harm Medicare’s largest value-based care program. MSSP accounts for 561 ACOs with 10.5 million Medicare patients, roughly 20% of Medicare. 

"Setting an application deadline two months after publishing the final rule does not give ACOs that have expiring agreements the necessary time to vet the decision internally or the time to process the many elements of the application," said NAACOS board member Jennifer Moore, COO at MaineHealth ACO in Portland, Maine.

"Given the significant changes, ACOs need to engage actuaries to understand how we would fare in downside risk. Such an analysis takes time. Without that time, we would have to enter an upside track out of the gate," Moore said.

Those new challenges include critical decisions on which physician and provider groups to include in the ACO, choosing risk levels and track participation, selecting waiver applications, and repayment options, Moore said.  

Complicating matters further, Moore said, is the March 1 deadline to apply for CMS's Bundled Payments for Care Improvement Advanced Model. Quality reporting for various Medicare programs is also done in January and February.

"Our ACO has more than 125 tax IDs that need to sign new agreements. On top of that, we must secure a letter of credit (banks indicate that is a six-to-eight-week process), evaluate the new waivers, and vet provider and supplier lists," Moore said. "I am hopeful that CMS will reconsider this aggressive timeline and balance the need to get started with the understanding that the application process takes planning time."

In its initial comments to the August proposed rule, NAACOS recommended that CMS allow ACOs with agreements expiring in 2018 to extend through December 31, 2019. NAACOS last June urged CMS to provide information regarding the expected timeline for 2019 applications so that ACOs could begin preparing for the condensed deadline.