Recognize Nurse Practitioner Practices as Medicare Shared Savings Accountable Care Organizations

ACTION NEEDED: Cosponsor HR 1160 to Improve the Way Beneficiaries Are Assigned Under the Medicare Shared Savings Program (MSSP)

This legislation would allow the assignment of patients seen only by nurse practitioners (NPs) to MSSP Accountable Care Organizations (ACOs). The Affordable Care Act recognizes NPs as professionals eligible to participate in MSSP ACOs. However, the statute prevents Medicare beneficiaries who receive their primary care services solely from NPs from being assigned based on their claims data to ACOs in the program. The Centers for Medicare and Medicaid Services (CMS) has interpreted this requirement to mean that a patient must receive at least one primary care service from a primary care physician each year in order to be assigned to an MSSP ACO. This restriction limits the ability of NP practices to independently join or establish their own MSSP ACOs.

Background

Section 3022 of the Affordable Care Act established the MSSP based on concepts developed by existing ACOs. ACOs create incentives for health care providers to work together to treat an individual patient across care settings. MSSP participants agree to lower the cost of health care while meeting identified performance standards by sharing resources and care in a coordinated manner. Patients are assigned to ACOs, and are counted towards the shared savings, based on claims data regarding which providers are providing care to the patient. The health reform law recognizes NPs as authorized “ACO professionals.”

However, historically, both the statute and regulations effectively prohibited NP practices from joining or establishing ACOs in this program by basing the claims-based assignment of beneficiaries on primary care services provided by a primary care physician. As a result, patients could not be assigned to an MSSP ACO without receiving at least one primary care service from a primary care physician each year. While this restriction does not prevent individual NPs from joining an ACO, it prevents their patients from being assigned to a Medicare Shared Savings ACO, and any benefits that result from such participation, unless the NP sends their patient to receive a primary care service from a primary care physician.

Recently, CMS created a pathway that will go into effect in 2019 for patients to choose an NP as their primary care provider in an MSSP ACO and be assigned to the ACO without requiring that the patient receive one primary care visit from a primary care physician. This change will provide greater opportunity for NPs and their patients to join and establish MSSP ACOs, but it is still imperative to retire the statutory barrier for claims-based assignment as well.

HR 1160 will amend Section 1899(c) of the Social Security Act, which limits the claims-based assignment of beneficiaries on the utilization of primary care services provided by primary care physicians. This language currently excludes the patients of NPs from assignment to Medicare Shared Savings ACOs without the patient receiving an unnecessary physician visit. The MSSP has demonstrated cost savings for the Medicare program while maintaining high-quality care, and it is imperative to fully include NPs and their patients in the MSSP in order to continue to improve patient access, quality and cost effectiveness.

Request

AANP calls on members of Congress to cosponsor HR 1160 to improve the way beneficiaries are assigned under the Medicare Shared Savings Program.

For additional information, please contact the AANP Government Affairs Office at 703-740-2529 or governmentaffairs@aanp.org.

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