Toward Accountable Payment

Publication Alert: Exploring the Pioneer ACO Model

by Rob Lazerow

The Centers for Medicare and Medicaid Services recently announced the Pioneer ACO Model, an advanced path to ACO formation for providers with prior experience managing risk. To help providers assess potential program participation, the Health Care Advisory Board published a whitepaper today highlighting eight key conclusions about the Pioneer ACO Model and reviewing critical details about the program's structure.

Since Medicare announced the Pioneer ACO Model last month, progressive providers have been considering this advanced option for forming ACOs to serve fee-for-service Medicare beneficiaries. Although similar to the Shared Savings Program (SSP) in many respects, the Pioneer Model offers an accelerated path for organizations that have prior experience managing risk-based contracts. The Pioneer approach offers more generous financial rewards and greater flexibility in program design than the SSP, but also elevates providers' financial risk and creates ambitious expectations about Pioneer ACOs shifting the bulk of their business to outcomes-based contracts across the coming years.

Building on our previous "First Take" analysis, the Health Care Advisory Board team continued to analyze the Pioneer ACO Model and prepared a detailed whitepaper to help members critically evaluate their potential participation in the Pioneer program. This whitepaper offers eight key conclusions about the Pioneer ACO Model and details critical aspects of the program's structure.

Key conclusions about the Pioneer ACO Model

I want to share some of our most important insights about the Pioneer ACO Model directly with the faithful readers of the "Toward Accountable Payment" blog. Again, download the whitepaper on to review the complete list of conclusions and full analysis. Our key conclusions include the following:

  • CMS "doubling down" on ACO model-Pioneer signals reinvestment in ACO concept after proposed Medicare Shared Savings Program (SSP) rules. The Pioneer ACO Model upholds several key elements of SSP, suggesting that CMS is not only maintaining, but strengthening its investment in the creation of ACOs. Yet, CMS innovation around ACOs continues to center on organizations most experienced in population management. With the unveiling of Pioneer, CMS offers a new and significant upside opportunity for those providers willing, and ready, to assume utilization risk immediately.
  • Only existing "ACOs" need apply. Pioneer's accelerated path to ACO formation places significant pressure on participating providers to have their proverbial ducks in a row on day 1 of the program. Because Pioneer participants will need to meet requirements above and beyond those in SSP, applicants must have the appropriate infrastructure and technology already in place, as well as serve a sizeable number of Medicare beneficiaries (15,000) at the onset of the program. Taken together with Pioneer's rapidly approaching application deadline, those organizations that do not have the capabilities to apply today are unlikely to be sufficiently ready to participate in Pioneer.
  • CMS leveraging first-mover ability to accelerate non-federal reimbursement policy transformation. For those organizations ready to apply to Pioneer, at least 50% of revenue must come from risk-based contracts, regardless of payer. It is unclear whether this policy is designed to provide another layer of exclusivity around participation or is meant to signal to health plans and providers that they need to accelerate transition to accountable payment. Regardless, CMS believes that Pioneer ACOs will achieve the most success by fully committing to an outcomes-based model, and is using Pioneer to accelerate payment transformation in the private sector.
  • CMS committed to intense quality reporting and performance regime for all ACO programs. The Pioneer ACO Model does not deviate from CMS's original pledge to a rigorous quality reporting and performance regime as regulated under SSP. ACOs will be measured on the same 65 quality metrics and will be subject to identical performance and reporting requirements to determine the percentage of bonus received.

Access the full whitepaper

Download "The Pioneer ACO Model: Program Details and Implications for Participating Providers" whitepaper to read our complete analysis of Medicare's recently announced Pioneer ACO Model. This whitepaper offers eight key conclusions about the Pioneer ACO Model and details critical aspects of the program's structure.

Is your organization applying to become a Pioneer ACO? As always, please feel free to email me with any questions you may have about the Pioneer ACO Model, Medicare Shared Savings Program, or payment reform more broadly.