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April 26, 2016

Patrick Conway, MD
Deputy Administrator for Innovation & Quality CMS Chief Medical Officer
Centers for Medicare & Medicaid Services 7500 Security Boulevard
Baltimore, Maryland 21244 

Dear Deputy Administrator Conway, 

We, the undersigned, strongly support CMS' drive towards value-based care, and your leadership in developing models within CMMI that support this goal. We have participated in value-based Medicare models such as the Next Generation ACO, Pioneer ACO, the Medicare Shared Savings Program ACO, the Physician Group Practice Demonstration and the Bundled Payment for Care Improvement models. 

We would like to bring to your attention a matter of critical importance to all of us: the current ACO/BPCI overlap policy that has the potential to tum delivery systems away from the ACO models - and particularly the most advanced Next Generation ACO model -- and reverse gains CMS has made toward its laudable goal of having 50% of Medicare payments in an alternative payment model by 2018. 

Under current policy, we believe that funds flow between the two models can negatively impact ACOs - particularly high performing ACOs -- to such a degree that it could make it difficult, if not impossible, for these ACOs to realize any shared savings. This will likely force high-performing ACOs and other low cost ACOs to withdraw from the ACO models, particularly the models with downside financial risk. 

CMS has a stated goal of supporting value-based payment models that link accountability for cost, quality and experience of care. The ACO models promote value at the highest level, with accountability for population cost, quality and experience over multiple years. The CMS ACO models were designed to hold ACOs accountable for the total cost of care of the Medicare beneficiaries aligned to them, regardless of where care is "initiated." However, the current overlap policy removes from ACO accountability the cost of care during a BPCI episode, while still holding the ACO accountable for patient experience and quality, de-linking the components of the three-part aim. 

We support CMS' approach to testing and evolving multiple approaches to deliver value, including BPCI models. However, we would strongly encourage you to look quickly into alternative approaches to the current overlap policy so that both ACO and BPCI models can thrive, and CMS can achieve its goals for the growth of alternative payment models. The current policy defaults to the benefit of bundled participants where other policy choices are possible. An alternative to the current overlap policy, that does not subject ACOs to BPCI target pricing, is particularly important now to support continued participation in ACO models.

Should you have any questions, please contact Emily Brower from Atrius Health at 617.559.8567 or at [email protected]. 

Thank you for your timely attention to this matter. Sincerely,

ABS Managed Care Administrators, Inc. Accountable Care Options, LLC Aledade, Inc.
Amarillo Legacy Medical ACO
American Health Network of Indiana, Inc. American Health Network of Ohio, PC AMGA
AmpliPHY Physician Services, LLC ApolloMed ACO
Ascension Atrius Health
Beth Israel Deaconess Care Organization Brown & Toland Physicians
Central MN ACO, LLC
CHESS NextGen, LLC a subsidiary of Cornerstone Health Enablement Strategic Solutions, LLC North Carolina
Circle Health Alliance, LLC
Collaborative Health Accountable Care Organization Collaborative Health Systems, A Universal American Company Crystal Run Healthcare ACO, LLC
Deaconess Care Integration Delaware Valley ACO Delmarva Health Network Evolent Health
Fairview Health Services
Franciscan Alliance Accountable Care Organization Geisinger Health System
Kentucky Primary Care Alliance
Keystone Accountable Care Organization, LLC Massachusetts Medical Society
Medical Home Network ACO
The Memorial Care Regional ACO
MetroWest Accountable Healthcare Organization MHT-ACO
Michiana Accountable Care Organization, LLC Michigan Pioneer Accountable Care Organization MissionPoint Health Partners
Monarch HealthCare
Mount Auburn Cambridge Independent Practice Association NAACOS
National ACO, LLC
NH Accountable Care Partners
Ohio Integrated Care Providers, LLC Optum Accountable Care
Palm Beach Accountable Care Organization, LLC
Premier healthcare alliance PremierMD ACO LLC ProHealth Solutions, LLC Prospect ACO CA
Quality Independent Physicians, LLC Reliance ACO LLC
Reliant Medical Group Select Health Network Sharp HealthCare
South Florida Accountable Care Organization, LLC 
ThedaCare ACO
Triad HealthCare Network 
Trinity Health 

Sean Cavanaugh, Deputy Administrator and Director, Center for Medicare
Dr. Hoangmai Pham, Chief lnnovation Officer and Acting Group Director, Policy and Programs Group Dr. Rahul Rajkumar, Deputy Director, Center for Medicare and Medicaid Innovation
Amy Bassano, Director, Patient Care Models Group