What Experienced with Medicare Risk Means?

Medicare determines if a newly formed Medicare Shared Savings Program (MSSP) ACO may proceed with forming a no-risk Medicare ACO based on the federal code of regulations definitions of experienced and inexperienced with performance-based risk.

Inexperienced with performance-based risk Medicare ACO initiatives means an ACO that Medicare determines meets all of the following:

(1) The ACO is a legal entity that has not participated in any performance-based risk Medicare ACO initiative, and has not deferred its entry into a second Shared Savings Program agreement period under a two-sided model; and

(2) Less than 40 percent of the ACO's provider participants participated in a performance-based risk Medicare ACO initiative, or in an ACO that deferred its entry into a second Shared Savings Program agreement period under a two-sided model, in each of the 5 most recent performance years.

Performance-based risk Medicare ACO initiative means an initiative implemented by Medicare that requires an ACO to participate under a two-sided risk model (shared savings/shared losses) during its agreement period, including the following options and initiatives:

• For performance years beginning prior to January 1, 2023, BASIC track (Levels A through E).
• For performance years beginning January 1, 2023 and in subsequent years, BASIC track (Levels C through E).
• ENHANCED track.
• Track 2.
• Pioneer ACO Model.
• Next Generation ACO Model.
• Comprehensive ESRD Care Model two-sided risk tracks.
• Track 1+ Model.
• Other initiatives involving two-sided risk as may be specified by Medicare.

Experienced with performance-based risk Medicare ACO initiatives means an ACO that Medicare determines meets either criteria (1) or (2) below.

(1) The ACO is the same legal entity as a current or previous ACO that is participating in, or has participated in, a performance-based risk Medicare ACO initiative as defined under this section, or that deferred its entry into a second Shared Savings Program agreement period under a two-sided model under.

(2) Forty percent or more of the ACO's participants participated in a performance-based risk Medicare ACO initiative, as defined under this section, or in an ACO that deferred its entry into a second Shared Savings Program agreement period under a two-sided model under, in any of the 5 most recent performance years.

Pros & Cons

As ACOs continue to recruit physician practices, it is important for these practices to understand the consequences of joining an at-risk organization. While a primary care physician participant may gain a bonus this year and higher Medicare physician fee schedule in the future, they also will be identified as an experienced with risk practice if they decide to join another organization in the future, unless Medicare sets an expiration date on such at-risk facility identification policies.

Looking into the future, if a practice decides not to continue participation at risk or the at-risk organization dissolves, the practices options would be limited to join no risk organizations (less than 40% prior at-risk practices can join) and/or face the possibility of losing the higher physician fee schedule.

Kris Gates, [email protected]