Is the ACO Primary Care Flex Model Right for You? Aledade Dives Deeper into New Model

March 28, 2024

As we await more details about the new model out of the Center for Medicare and Medicaid Innovation, we take a look at what challenges ACO Flex aims to solve, and what accountable care organizations need to consider when making the decision to join the model. For an even deeper dive, watch our on-demand webinar.

By Casey Korba, Director of Policy

The Center for Medicare and Medicaid Innovation (CMMI) announced a new model – ACO Primary Care Flex – that aims to help the agency reach the goal of getting 100% of beneficiaries into an accountable care relationship by 2030. More than a decade of evidence has shown that accountable care relationships are critical in order to deliver high quality care, patient satisfaction, and concurrently lower costs for the patient, health care system, and taxpayer. In 2021, after close to seven years of working with primary care practices to achieve success in the ACO model, Aledade outlined why the Medicare Shared Savings Program (MSSP) – the flagship, permanent ACO program – should be the chassis for innovation. A central element of Flex is the dual participation requirement. ACOs must be in MSSP, either joining during the May/June application cycle or renewing their participation, to participate in Flex. We know through data from other models, such as Comprehensive Primary Care Plus, that pairing a model with MSSP is important to helping ACOs succeed and critical to test out new innovations that are working in other models. 

Prospective Primary Care Payments will help ACOs innovate care delivery 

Flex sets out to test if more timely payment for primary care, through monthly prospective payments and enhanced payments, will enable participating ACOs and primary care clinicians to focus even more on team-based, person-centered and proactive approaches to care and positively impact health outcomes, quality, and costs of care. While MSSP contains just a few drawbacks, one of those drawbacks, for many ACOs, is difficult: ACOs must wait 18 months to receive their shared savings. Flex resolves that problem through its provision of monthly prospective primary care payments (PPCPs) while also freeing up fee-for-service (FFS) dollars. Beyond that, the model also features a one-time infrastructure payment to the ACO.

Prospective payments will enable ACOs to reduce their dependence on FFS codes and give them room to innovate care delivery. While we don’t immediately have all the details on how these payments will be structured, we know that these are monthly, consistent payments that will replace FFS payments for primary care services (Evaluation and Management and similar codes billed by primary care clinicians for assigned patients but not procedure-based codes). Practices will continue to submit those claims, but CMS will zero out the listed primary care services and, instead, remunerate those services through the monthly payments from the ACO. 

The prospective payments are comprised of two parts. The first is a County Base Rate to cover eligible services derived from the average primary care spend in their county. The second is an Enhanced Amount for providing enhanced primary care services based on characteristics of the ACO and assigned patient population. We are expecting more information on the amount of these payments in the coming weeks. The calculation of the total cost of care benchmark for ACOs participating in Flex will be unchanged from MSSP’s methodology. CMS estimates that for most Flex participants, the prospective payments will increase primary care funding. Aledade will be performing this analysis for any interested member ACO. 

Federally Qualified Health Centers and Rural Health Clinics are eligible for Flex

CMS has set a goal to incentivize more safety net providers, including Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), to participate in value-based care. FQHCs and RHCs are not paid fee-for-service (FFS) and CMS recognizes that a beneficiary-level adjustment to the PPCP is needed. The all-inclusive payment rate is different for FQHCs and RHCs and there will be a different primary care per-beneficiary per-month (PBPM) adjustment amount to encourage FQHCs and RHCs to participate in the model.

Is the Flex model right for my ACO?

The Flex model application process opens in May, with the performance year beginning January 1, 2025. That means that now is the time for ACOs to start their decision-making process. Participation in Flex is at the ACO level rather than the practice level. ACOs will need to evaluate different variables to decide if the Flex model is right for them, and Aledade is here to help our member ACOs with that decision. ACOs will need to decide how they innovate care delivery for patients and practices. Many might find that they can rely less on time tracking for services like chronic care management. They also may experience more flexibility in how they structure their days caring for patients. Many ACOs might be excited about the ability to create new partnerships, hire additional care coordination staff, or go further in addressing unmet health related social needs in their patient population. 

It’s also possible that ACOs may experience all of those benefits.

For more information, watch Aledade’s webinar on the Flex model and stay tuned for more details.