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December 21, 2021 

The Hon. Derek Kilmer 

U.S. House of Representatives
2059 Rayburn House Office Building
Washington, DC 20515

The Hon. Adrian Smith 

U.S. House of Representatives
502 Cannon House Office Building
Washington, DC 20515

The Hon. Kathleen Rice

U.S. House of Representatives
2435 Rayburn House Office Building
Washington, DC 20515

The Hon. Mike Gallagher

U.S. House of Representatives
1230 Longworth House Office Building
Washington, DC 20515


Dear Reps. Kilmer, Smith, Rice, and Gallagher: 

The National Association of Accountable Care Organizations (NAACOS) writes to endorse the ACO Assignment Improvement Act of 2021, H.R. 6308. This legislation will both improve patients’ access to care, especially in rural America and reduce inequities by removing the statutory requirement that patients have at least one primary care visit with a physician during the year in order to be assigned to an ACO. Removing this requirement will allow nurse practitioners, physician assistants, and other non-physician providers (NPPs) to contribute toward ACO assignment even if their patients never see a physician for a qualifying visit during the year.  

NPPs already play an important role in ACOs. They meaningfully contribute to ACOs’ high-quality care in a variety of ways such as following up with patients recently discharged from the hospital or in post-acute care settings and managing patients’ chronic diseases. While the care they provide already counts in ACO assignment, removing the physician-visit requirement will enhance NPPs’ role within ACOs. Assignment is a critical program methodology that determines the beneficiary population for which an ACO is held accountable for quality and cost. Accountable care is working. ACOs have saved Medicare $13.3 billion in gross savings and $4.7 billion in net savings since 2012. Importantly, data show these ACOs continue to provide high-quality care and yield satisfied patients. Today, ACOs care for nearly 20 percent of all Medicare patients and nearly a third of traditional Medicare patients. 

Research conducted by the Institute for Accountable Care shows ACOs’ attributed populations will grow by an average of 3.4 percent under this bill. Rural ACOs, those more focused on home-based care, and those serving larger numbers of nursing home patients will see larger growth. Importantly, there should be little impact to the overall clinical severity of ACOs’ patients. 

NAACOS supports this bill, which will expand accountable care to more beneficiaries. However, we are concerned about an existing assignment flaw related to CMS’s inability to differentiate between NPPs practicing primary care compared to those practicing specialty care. The American Association of Nurse Practitioners states 70 percent of all nurse practitioners deliver primary care, but CMS is unable to make this distinction based on a lack of NPP designations in its systems. NPPs play a prominent role in our healthcare system and those that deliver primary care, as opposed to specialty care, should play a prominent role in ACO assignment. 

As our healthcare system shifts to one that’s focused more on value-based payment and accountable care, it’s important to understand the care that’s being provided so that we can better manage and appropriately pay for that care. We continue to advocate that ACOs be permitted to remove specialty-focused NPPs from assignment. This change, coupled with those in the ACO Assignment Improvement Act, would ensure a meaningful and appropriate role of NPPs in ACO assignment. We look forward to working with your office as this bill undergoes review by committees of jurisdictions to make necessary changes to distinguish NPPs who practice primary care and those who practice specialty care.

We greatly appreciate your commitment to this bill and extending value-based care to more patients. Please let us know how we can be a resource to ensure that we can grow accountable care models and support both providers operating in them and patients served by them.


Clif Gaus, Sc.D.
President and CEO