RISE summarizes recent regulatory-related headlines.
ACOs call for extension of ACO REACH following reports of record savings
New data from the Centers for Medicare & Medicaid Services (CMS) indicates that 132 accountable care organizations (ACOs) in the ACO REACH Model collectively generated $1.6 billion in gross savings and $695 million in net savings after accounting for shared savings and losses.
Ninety-six ACOs (73 percent) earned net savings, and ACOs were able to reinvest $948 million in savings to provide better patient care leading to improved quality scores between 2022 and 2023, noted Aisha Pittman, senior vice president of government affairs of the National Association of ACOs (NAACOS), in an announcement.
“Despite the lack of opportunities for new ACOS to join, the ACO REACH Model has continued to grow in the number of participating clinicians, with more than 173,000 participating in 2024. This growth, coupled with strong performance, highlights the value in ACO REACH empowering clinicians to deliver more innovative care for traditional Medicare patients. For example, ACO REACH allows providers to offer benefits to traditional Medicare beneficiaries not otherwise allowed like cost sharing waivers, chronic disease management rewards, and more flexible care in the home.”
NAACOS, Pittman said, urges CMS to ensure that high-performing clinicians in the ACO REACH Model are provided a clear and predictable pathway forward. “Given the model’s proven success, we strongly encourage CMS to extend ACO REACH beyond its current expiration date of 2026, while continuing to refine and develop new total cost of care models that will drive long-term improvements in the quality and affordability of care.”
WSJ report: MA members in last year of life more likely to switch to traditional Medicare
A new investigation by the Wall Street Journal reveals a pattern of Medicare Advantage’s sickest members switching to traditional Medicare when they run into roadblocks getting their care covered.
The publication analyzed Medicare claims and enrollment records they obtained under a research agreement with the federal government. It calculated and reviewed rates at which Medicare Advantage members within a year of their death ditched their health plans for traditional Medicare. The research looked at switchers over a six-year period from 2016 to 2022. They found that Medicare Advantage members in their final year of life switched to traditional Medicare at double the rate of other enrollees during that period.
One possible reason for the higher number of switchers: Sicker patients with Medicare Advantage may find it difficult to access services if their plan requires prior authorization and denies the services. A recent report by the U.S. Senate Permanent Subcommittee on Investigations found three of the largest Medicare Advantage insurers intentionally denied prior authorization requests for care in post-acute care facilities to boost profits.
“These are some of the costliest services, received by some of the costliest patients,” Claire Ankuda, a physician and researcher at Mount Sinai Hospital in New York, told the Wall Street Journal. “Plans are strongly motivated to reduce the cost of care delivery.”
But insurers interviewed by the publication said that most Medicare Advantage members are satisfied with their plans and patients at the end of life might switch to other coverage for various reasons, such as moving out of state.
OIG: Nearly half of hospitals haven’t complied with Hospital Price Transparency Rule
A new audit conducted by the Office of Inspector General (OIG) has found that not all of the selected hospitals made their standard charges available to the public as required by the federal Hospital Price Transparency Rule. The law requires hospitals establish, update, and make public their standard charges for items and services they provide in both a machine-readable file of all items and services and a consumer-friendly list of standard charges for a limited set of shoppable services.
Of the 100 hospitals in the OIG’s stratified random sample, 37 did not comply with one or both of the rule requirements. Thirty-four failed to comply with requirements associated with publishing comprehensive machine-readable files and 14 didn’t comply with the provision to display shoppable services in a consumer-friendly manner.
Based on the sample results, OIG estimates that 46 percent of the 5,879 hospitals that are required to comply with the pricing transparency rule did not comply with the requirements to make information on their standard charges available to the public.
The watchdog recommends that CMS review noncompliant hospitals associated with the findings and, if CMS determines that the hospitals are noncompliant, the agency should implement enforcement measures. In addition, CMS should use the information in the report to implement changes that hospitals suggested, such as providing written guidance clarifying the definition of “shoppable services” and developing a training and compliance program tailored for smaller hospitals. Finally, OIG suggests CMS improve its internal controls, to include allocating sufficient resources to maintain a robust program of reviews of the hospitals and their compliance with the pricing transparency rule. CMS concurred with all the recommendations and provided a list of corrective actions it has taken before, during, and after the OIG’s audit.