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August 1, 2022

Admiral Rachel L. Levine, MD
Assistant Secretary for Health
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Judith Steinberg, MD
Senior Advisor, Office of the Assistant Secretary of Health
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201


RE: HHS Initiative to Strengthen Primary Health Care Request for Information 

Dear ADM Levine and Dr. Steinberg: 

The National Association of ACOs (NAACOS) appreciates the opportunity to submit comments in response to the request for information (RFI) on strategies the federal government could pursue to strengthen primary health care in the United States. NAACOS represents more than 400 accountable care organizations (ACOs) that serve more than 13 million beneficiaries in a variety of value-based payment and delivery models in Medicare, Medicaid, and commercial insurers. NAACOS is a member-led and member-owned nonprofit organization that works to improve quality of care, health outcomes, and healthcare cost efficiency. We applaud this important initiative to strengthen primary care and support the administration’s goal to strengthen access to equitable, high-quality and affordable health care. Our comments below reflect our shared goals, and policy recommendations for the department to implement and advance these goals. 

Topic 1: Successful models or innovations that help achieve the goal state of primary health care
ACOs are groups of doctors, hospitals, and other health care providers that work collaboratively to improve quality of care, care coordination, and patient outcomes, reducing fragmented and unnecessary care. Primary care is the cornerstone of the ACO model as ACOs with a strong foundation of primary care are more successful. ACOs improve quality while controlling costs through primary care-focused initiatives such as expanded primary care teams, care coordination strategies, and enhanced data and analytics tools for primary care practices. The COVID-19 pandemic highlighted that independent primary care practices participating in ACOs were better-equipped to respond to the crisis, adapting ACO infrastructure to rapidly meet patients’ needs. Many ACO strategies and goals are closely aligned with HHS’ goal state of primary care, including initiatives to identify health equity gaps and partner with community-based organizations (CBOs) to address patients’ social needs. Given the administration’s focus on expanding accountable care and addressing health equity, ACOs should be leveraged to realize the goal state of primary care. 

Topic 2: Barriers to implementing successful models or innovations
The current fee-for-service (FFS) payment model has historically undervalued primary care and high-value preventive services. Efforts to better support primary care in a fee-based system have been unsuccessful, and many primary care leaders agree that FFS is ill-suited to primary care and does not sufficiently incentivize comprehensive, coordinated care delivery. While ACOs are incentivized to invest more in primary care, they still largely operate within the FFS structure and require time and resources to shift focus to primary care. 

Certain policies in the Medicare Shared Savings Program (MSSP), one of the largest and most successful ACO programs in operation, may hinder primary care transformation efforts. Two key barriers are:

  • Lack of guidance on use of waivers for self-referral (Stark Law) and anti-kickback (AKS) statutes. The use of these waivers has been a cornerstone for MSSP; however, there has been little uptake with the recent revisions to the Stark and AKS exceptions for value-based arrangements due to the lack of guidance. Increased guidance will enable ACOs to enhance their care coordination activities.
  • Lack of incentives to shift beneficiary cost sharing. While the MSSP Beneficiary Incentive Program (BIP) is intended to help eliminate financial barriers to accessing care, the program requires that incentives are provided to all beneficiaries regardless of financial need or condition. As a result, the program is too costly and complex for most ACOs. Targeted beneficiary incentives (similar to what is being tested in ACO REACH) would allow ACOs to better focus beneficiary care and ultimately bolster primary care.

Topic 4: Proposed HHS actions
In order to achieve the goal state of primary health care as outlined by HHS and address barriers in current systems, NAACOS recommends the following actions:

  • Implement a primary care capitation option.  We join the numerous stakeholders that recommend allowing MSSP ACOs to elect to receive capitation payments for primary care. This can help break the FFS “wheel” and allow more flexibility to transform care delivery. Optional capitation payments would allow ACOs to reallocate resources to advance primary care innovation and transformation.
  • Provide flexibility and guidance to support integration.As discussed above, additional guidance is needed on recent modifications to Stark Law and AKS regulations and ACOs need enhanced flexibility to offer beneficiary incentives.  We also recommend telehealth waivers be expanded to allow all ACOs the flexibility to use telehealth in broader circumstances. The COVID-19 public health emergency highlighted the importance of telehealth and the need to modernize telehealth requirements in Medicare. Because ACOs are responsible for total cost of care for the populations they serve, they should be given appropriate tools to manage their populations, including telehealth. Existing safeguards in MSSP also provide an opportunity for CMS to test broader telehealth coverage within ACOs before expanding more permanent flexibilities to all of traditional Medicare.
  • Continue to pursue and refine policies and programs designed to address equity. We applaud the administration’s efforts to advance accountable care and address health equity, including the new ACO REACH Model under the CMS Innovation Center and the recently-proposed addition of upfront payments for certain new ACOs joining MSSP. These efforts will encourage primary care practices to participate in ACOs. We encourage HHS to continue to refine these programs and adapt other strategies NAACOS recommends for addressing health equity, including additional funding. Developing and implementing health equity initiatives requires data, infrastructure, relationships with CBOs, and other resources, and existing ACOs in underserved communities should also be provided appropriate funding to support this work. Additionally, advancing standardized collection of patient-reported demographic and social risk factor data is a critical step. 

We see ACOs as a strong lever to advance primary care towards the goal state outlined by HHS. Several recommendations that NAACOS has long advocated for would support primary care led ACOs and the advancement of care delivery transformation:

  • Improve and expedite ACOs’ access to data, including substance use disorder-related data, to enhance ACOs’ ability to coordinate beneficiary care
  • Ensure ACO quality requirements are thoughtfully designed and implemented to mitigate unintended consequences and incentivize equitable health outcomes
  • Develop an additional option within MSSP including full risk and capitation
  • Streamline ACO processes to reduce unnecessary burdens on providers that contribute to widespread burnout and may deter participation in ACO models

Thank you for the opportunity to provide feedback on the HHS initiative to strengthen primary health care. NAACOS and its members are committed to providing the highest quality care for patients while advancing population health goals for the communities they serve. If you have additional questions, please contact Aisha Pittman, senior vice president, government affairs at [email protected]


Clif Gaus, Sc.D.
President and CEO