The Opportunity for Palliative Care in ACO Flex (2024)

On Jan. 1, 2025, the Center for Medicare and Medicaid Services (CMS) Innovation Center will begin implementing a payment model for primary care known as the Accountable Care Organizations (ACOs) Primary Care Flex Model under the Medicare Shared Savings Program (MSSP).

The ACO Flex Model is a voluntary initiative to improve funding and other resources to support primary care delivery within the MSSP. The model encourages the formation of new, physician-led ACOs, particularly those serving underserved communities and addressing health disparities.

This program is not just a test but also seeks to empower participating ACOs and their primary care providers to employ more innovative, team-based, person-centered and proactive approaches to care.

ACOs participating in the model will jointly enroll in the Shared Savings Program and the ACO Flex Model. They will receive a one-time Advanced Shared Savings Payment, monthly prospective, population-based payments, and Prospective Primary Care Payments.

The model is designed to establish a consistent rate of health care spending across regions. This rate consists of two main elements: a county-based rate and payment enhancements, where applicable.

A one-time Advanced Shared Savings payment is provided to help cover the initial costs of forming an ACO and the administrative expenses associated with model activities. This financial support is a critical aspect of the ACO Flex Model, demonstrating CMS’s dedication to facilitating the transition to this new payment model.

“The way [CMS is paying] the revenue every month with advanced payments upfront should give providers opportunities to make better investments and identify primary care partners in a community or pull partners into the ACO,” Jake Hochberg, vice president of analytics and chief analytics officer at Boston-based Arcadia, told Palliative Care News in an interview.

Collaborating with ACO Flex Model participants could enable palliative care operators to utilize their unique skill sets to reach more patients. The role of a palliative care provider is crucial in this model.

Those providers can engage with ACOs in two ways: by becoming members of those organizations or by contracting with them through a preferred provider network. In preferred provider arrangements, the two parties can negotiate mutually beneficial terms tailored to their patient population’s specific needs and characteristics. This may become increasingly important as CMS has announced plans to ensure that 100% of Medicare beneficiaries are aligned with an ACO.

“While the model is primary care focused, the target goal is to bring low revenue models into value-based care arrangements,” Hochberg said. “This fits nicely into palliative care. Improved end-of-life care is also much better for patients and creates significant savings for health care systems.”

“The CMS Innovation Center understands that palliative and hospice care are critical to a patient’s care journey, and we anticipate that the ACO PC Flex Model’s focus on primary care will help increase access to palliative care and hospice for individuals with Medicare,” a CMS spokesperson told Palliative Care News.

Though the model description does not use the term “palliative care” explicitly, the principles underlying those services are baked into the program, according to Edo Banach, partner at Washington, DC-based Manatt, Phelps & Phillips.

“One of the goals of the ACO Flex Model is ‘to spur innovative approaches to care delivery, such as team-based care that is proactive and person-centered and drives quality improvement.’ That sounds like a description of quality palliative care to me,” Banachh told Palliative Care News. “Helping people and their families manage serious illness in a proactive and team-based way is what palliative care does and will be a crucial component of any successful primary care-based ACO.”

Banach said that palliative care providers can partner with primary care providers or, in some cases, can even apply to be part of the ACO Flex Model if they meet the requirements. He further surmised that those participating in the GUIDE Model might be in a perfect position, given that the ACO Flex and GUIDE Models overlap.

“It is crucial that primary care providers build out their partner networks and that potential partners connect with primary care companies as soon as possible,” Banach said. “I am convinced that without the right technology and partners, a primary care provider will be unable to make it. This is not a go-it-alone model. Like most things in health care – and life – this model requires collaboration and partnership.”

If palliative care providers are trying to demonstrate value, studies are proving the impact of their services, and providers should make use of those showing that better management translates to better outcomes.

“Show the reduction in spending when patients transition to end-of-life care early – about ten days before passing,” he said. “Show the number of patients that can be managed through palliative care and your capacity. When you become an ACO with Medicare, that is a public record. From the palliative care side, you can identify who in your market is joining ACO Flex. There is an opportunity to proactively engage provider groups and ensure they know the value of palliative care.”

From a provider side, when you enter a value arrangement for the first time, you will receive new data you were previously not getting, Hochberg indicated. Opportunities exist within those data to identify patients for palliative care, and providers can use this Value-based care creates an incentive to engage patients and improve their quality of care proactively, he said.

Demonstrating a track record of high quality outcomes is essential, according to Banach.

“Most importantly, palliative care providers can discuss their track record – be it a palliative care demo, Medicare Advantage relationships, or any other value-based approaches to care,” he said. “Speak about specific populations or conditions and show where a team-based approach can help prevent unnecessary care and provide more proactive, equitable access to care. I would also strongly suggest a partnership with a good technology vendor to help demonstrate value.”