Urgent Accountable Care Organization

Innovative “PC Flex” Model

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by

Mohan Gounder
in

The ACO Primary Care Flex Model (PC Flex Model) is a new initiative by the Centers for Medicare & Medicaid Services (CMS) designed to support primary care within low revenue Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. UACO is applying to be the only urgent care-focused ACO to test the benefits of such a model for urgent care with payment transformation starting in 2025.

Background and Objectives:

  • Purpose: The model aims to reduce healthcare costs and improve quality of care and health outcomes for Medicare beneficiaries by aligning financial incentives with primary care.
  • Duration: The model will be tested over five years, from January 2025 to December 2029.
  • Target ACOs: Focuses on low revenue ACOs, typically smaller and physician-led

Key Features:

  1. Payment Mechanisms:
  • Prospective Primary Care Payments (PPCP): Monthly population-based payments to support primary care, encouraging a shift away from fee-for-service models.
  • Advance Shared Savings Payment: A one-time payment to cover costs related to forming an ACO and administrative expenses.

2. Beneficiary Engagement:

    • The model uses the Shared Savings Program’s beneficiary assignment processes, which include voluntary and claims-based assignment methods.
    • A special focus on beneficiaries receiving primary care services at FQHCs and RHCs.

    3. Eligibility and Participation Requirements:

      • ACOs must be eligible for the Shared Savings Program and categorized as low revenue.
      • ACOs must not participate in other CMS initiatives that involve shared savings.
      • ACOs must establish a repayment mechanism to ensure their ability to repay any amounts owed under the model.

      4. Application Process:

        • Applications are submitted in phases, with specific timelines for each phase.
        • ACOs need to provide detailed application information, including a Spend Plan and roster of non-physician practitioners.

        5. Health Equity Focus:

          • The model includes several health equity-promoting policies, such as:
            • Adjustments to PPCP rates based on county-level spending and beneficiary-specific equity scores.
            • Requirements for ACOs to develop and implement health equity plans.
            • Collection and reporting of health equity data.

          6. Monitoring and Evaluation:

            • CMS will monitor ACOs’ compliance with the model’s requirements and may take remedial actions if necessary.
            • The model includes rigorous safeguards and reporting requirements to ensure proper use of funds and achievement of health equity goals.

            Goals:

            • Improvement in Care: Enhance the quality and accessibility of care while reducing disparities in health outcomes.
            • Cost Reduction: Lower overall healthcare costs through innovative, team-based, and proactive care approaches.
            • Equitable Care: Ensure that payment and care delivery mechanisms address health disparities and support underserved communities.

            The ACO PC Flex Model represents a strategic effort by CMS to leverage primary care as a platform for broader healthcare system reform, emphasizing flexibility, innovation, and a strong commitment to health equity.