NAACOS Offers Guidance for Hybrid Primary Care Payment Model in MSSP

The National Association of ACOs (NAACOS) is calling on CMS to establish a hybrid primary care payment model in the Medicare Shared Savings Program (MSSP) using two possible approaches that will provide flexibility for accountable care organizations (ACOs).

Primary care access suffered during the COVID-19 pandemic due to a lack of investment and administrative burden. Research has shown that shifting primary care payment toward hybrid models that include prospective population-based payments and per-visit payments may help create a stronger primary care system.

In March, NAACOS and 26 other healthcare organizations sent a letter to CMS asking the agency to implement a new hybrid primary care payment option in MSSP. The letter detailed six principles that should govern the approach.

The model should consider health equity, result in increased investment in primary care, be fully voluntary, and be available rapidly and in all locations. Additionally, the model should include value for beneficiaries and the Medicare program.

NAACOS and the Primary Care Collaborative (PCC) met with ACOs and primary care stakeholders to further discuss what a hybrid payment option in MSSP should look like. They landed on three additional considerations that should inform CMS’ decision to establish the model.

First, there cannot be one singular model for all ACOs. Primary care needs differ depending on the community. In addition, ACOs and primary care practices may have varying capabilities for managing population-based payments.

Second, additional support may be needed to encourage new participants to join MSSP and ensure rural, independent, and safety-net practices succeed.

Third, the organizations reiterated the importance of investing in primary care. They noted that it wouldn’t be easy under CMS’ current requirements for models. However, they said that recouping the increased primary care payments through future shared savings will help support increased investment in primary care.

“These strategies recognize the longer-term ROI of advanced primary care and the time it takes for new ACOs to generate shared savings,” the NAACOS blog post stated.

NAACOS proposed two payment approaches that CMS should offer to help encourage broad participation in the hybrid primary care payment model.

The first approach consists of CMS paying prospective and per-visit payments directly to the primary practices, with a portion paid to the ACO. Practices and ACOs would agree on an option based on practice capabilities and the services included in the capitated payments.

The portion of the payment for the ACO could be used to fund infrastructure, data analytics, care coordination services, and performance incentives for delivering quality care. Thus, this approach would likely work for ACOs that lack the infrastructure and experience to administer payments to practices.

The second approach would include CMS making payments directly to the ACO, which then administers the capitated payments to participating primary care practices. This approach is similar to the methodology being tested in the ACO Realizing Equity, Access, and Community Health (REACH) model.

This route would likely suit ACOs with the experience and infrastructure to pay practices. Both the ACO and primary care practice would agree on the downstream payment arrangement. Additionally, payments from the ACO could include a bonus pool or other incentives to reward quality care delivery.

“Guided by the principles described above, a hybrid primary care payment option in MSSP can help Medicare, primary care practices, and ACOs deliver better health,” the blog post stated. “We encourage CMS to rapidly implement these approaches. CMS should send a clear signal of agency action on the proposal this year.”