ECONOMIC REPORT OF THE PRESIDENT

orient payment around the entirety of the care a patient receives during the
year, rather than just the care delivered during a particular episode of care.
Under an ACO model, a group of providers join together and agree to be
held accountable for the overall cost and quality of the care their patients
receive during a year. ACOs that reduce average per beneficiary spending
below a “benchmark” level share a portion of the savings, giving providers
a strong incentive to deliver care more efficiently. (Certain ACO models are
“two-sided,” meaning that providers also agree to repay a portion of any
spending in excess of the benchmark.) ACOs that perform well on a suite of
measures of the quality of the care they deliver are eligible for larger financial
rewards, giving them a strong incentive to deliver high-quality care and a
corresponding disincentive to limit access to necessary care.
ACOs are now widespread in the Medicare program. As of January
2016, 8.9 million traditional Medicare beneficiaries—nearly a quarter of
the total—were receiving care through more than 470 ACOs, as illustrated
in Figure 4-25. The substantial majority of these beneficiaries are aligned
with ACOs operating under the Medicare Shared Savings Program, the
permanent ACO program created under the ACA. A smaller number are
participating in ACO models being tested by CMMI that aim to improve
upon existing ACO models in a range of ways. These CMMI ACO models
include: the Next Generation ACO; the Comprehensive ESRD Care Model,
which aims to improve outcomes for patients with a particular high cost,
high risk condition; and the ACO Investment Model, which supports the
participation of small practices or practices in rural areas. Notably, an earlier
CMMI ACO model—the Pioneer ACO model—became the first model to
meet the criteria for expansion under the Secretary’s expansion authority
(L&M Policy Research 2015; Spitalnic 2015; HHS 2015). Features of the
Pioneer ACO model have now been incorporated into the Medicare Shared
Savings Program on a permanent basis.
Through CMMI, the Administration has also tested a range of other
innovative payment approaches in addition to bundled payments and
ACOs. For example, CMMI is testing medical home models that provide
additional resources to primary care practices that agree to engage in a set
of specified activities, including care management and care coordination
activities, and to be held financially accountable for the cost and quality of
the care their patients receive. CMMI began its first major test of medical
homes through the Comprehensive Primary Care Initiative, which began
operating in October 2012; currently, there are 442 participating practices
in seven states. In early 2016, CMMI announced an improved medical home
initiative, known as the Comprehensive Primary Care Plus model, which
will begin operating in 16 states in January 2017. In collaboration with the
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