In an effort to address financial barriers to accountable care organizations’ (ACOs’) provision of primary care services, Medicare will test a new value-based payment model for approximately 130 starting in 2025 and running through 2029.
The ACO Primary Care Flex Model aims to grow participation in the Medicare Shared Savings Program (MSSP), reduce disparities in health care outcomes and access to advanced primary care, and lower costs while enhancing quality of care, according to a Centers for Medicare & Medicaid Services (CMS) fact sheet.
Newly-formed and existing low-revenue ACOs that participate in the MSSP and meet the model’s other eligibility requirements may apply.
Low-revenue ACOs tend to be smaller and mainly made up of physicians. Forty-two of Texas’ 54 ACOs qualified as low-revenue during the 2022 performance year, the latest for which data is available, according to CMS.
Prospective applicants first must apply to the MSSP, whether as new or renewing ACOs, between May 20 and June 17. Applications for the model will be due in early August.
ACOs that participate in the model will receive:
- A one-time advanced shared savings payment of $250,000 to cover costs associated with forming an ACO, if applicable, and other required model activities; and
- Monthly prospective, population-based payments – made up of the county base rate, based on the county’s average primary care spending, and payment enhancements based on the ACO’s characteristics and its assigned patient population – to be distributed to member clinicians in lieu of fee-for-service payment for primary care services.
Under the model, ACOs will submit claims as usual, but Medicare payment systems will “zero out” claims for primary care services billed to assigned patients.
TMA experts caution potential physician participants to review their participation agreements carefully and to seek the advice of an attorney as Medicare payment for primary care services would come from their ACO rather than from Medicare during the model’s duration.
Interested ACOs also should be prepared to demonstrate the capabilities and procedures necessary to distribute monthly payments to physicians.
For more information, visit the CMS’ ACO Primary Care Flex Model webpage.
Last Updated On
April 10, 2024
Originally Published On
March 25, 2024
Emma Freer
Associate Editor
(512) 370-1383