Accountable Care Organization Investment Model (AIM)

Accountable Care Organization Investment Model (AIM)

**This fact sheet was updated on 03/24/2017**

Overview Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to provide coordinated, high-quality care to their Medicare patients to help them deliver better care at lower cost.

The goal of coordinated care is to ensure that patients, especially people with chronic conditions, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

ACOs represent one part of a comprehensive series of initiatives in the Affordable Care Act that are designed to lower costs and improve care. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

Medicare currently offers several ACO initiatives:

• Medicare Shared Savings Program (Shared Savings Program)
• Next Generation ACO Model (NGACO)
• ACO Investment Model (AIM)
• Comprehensive End Stage Renal Disease (ESRD) Care Initiative

This fact sheet provides a general description of AIM, an ACO model being offered to support Shared Savings Program ACOs. The Shared Savings Program provides financial incentives for ACOs to lower growth in health care costs while meeting performance standards on quality of care and putting Medicare beneficiaries first. Summary of the ACO Investment Model AIM is an initiative developed by the Center for Medicare and Medicaid Innovation (Innovation Center) designed for organizations participating as ACOs in the Shared Savings Program. AIM is a model of pre-paid shared savings that builds on the experience with the Advance Payment ACO Model to encourage new ACOs to form in rural and underserved areas and current Shared Savings Program ACOs to transition to arrangements with greater financial risk. The model is expected to provide a total of $96 million in upfront and ongoing investments to AIM participants.

AIM was available to:

1. New Shared Savings Program ACOs that joined in 2015 or 2016. AIM seeks to encourage uptake of coordinated, accountable care in rural geographies and areas where there has been little ACO activity, by offering pre-payment of shared savings in both upfront and ongoing per beneficiary per month payments. CMS believes that encouraging participation in areas of low ACO penetration may spur new markets to focus on improving care outcomes for Medicare beneficiaries.

2. ACOs that joined the Shared Savings Program starting in April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014. Here, AIM helps ACOs to succeed in the Shared Savings Program and encourages progression to higher levels of financial risk, ultimately improving care for beneficiaries and generating Medicare savings.

Participants AIM consists of 45 participating ACOs across 38 states, including 2 ACOs selected for a 2015 AIM start and 43 ACOs selected for a 2016 AIM start. Both ACOs selected for a 2015 AIM start began participating in the Shared Savings Program in 2013. Of the 43 ACOs selected for a 2016 AIM start, 2 are 2014 Shared Savings Program starters, 5 are 2015 Shared Savings Program starters and 36 are 2016 Shared Savings Program starters.

Number of Beneficiaries: As of January 2017, AIM participants serve a combined total of over 487,000 beneficiaries nationwide; an increase of 53,000 beneficiaries from January 2016.

ACO Infrastructure: 27 ACOs report having a Critical Access Hospital (CAH) or Inpatient Prospective Payment System (IPPS) hospital with fewer than 100 beds as part of their ACO structure.

Geographic Coverage of AIM Participants:

List of AIM ACOs:

• Access Care Oklahoma, LLC
• Affiliated ACO, LLC
• Akira Health of Los Angeles Inc
• Akira Health, Inc
• Aledade Kansas ACO, LLC
• Aledade Mississippi ACO, LLC
• Aledade West Virginia ACO, LLC
• Alliance ACO, LLC
• AmpliPHY of Kentucky ACO LLC
• AmpliPHY of Texas ACO LLC
• Beacon Rural Health
• California ACO
• Carolina Medical Home Network Accountable Care Organization LLC
• Citrus County ACO, LLC
• Deep South Regional ACO
• Great Plains Care Organization
• Greater Michigan Rural ACO
• Heartland Physicians ACO, Inc.
• High Sierras-Northern Plains ACO
• Illinois Rural ACO
• Illinois Rural Community Care Organization LLC
• Indiana Rural ACO
• Iowa Rural ACO
• Kentucky Primary Care Alliance
• Magnolia-Evergreen ACO
• Minnesota Rural ACO
• MissouriHealth+
• Mountain Prairie ACO
• Mountain West ACO
• New Hampshire Rural ACO
• North Mississippi Connected Care Alliance
• Ohio River Basin ACO
• Oregon - Indiana ACO
• Prairie Hills Care Organization
• PremierMD ACO, LLC
• Reid ACO
• Rocky Mountain Accountable Care Organization, LLC
• San Juan Accountable Care Organization, LLC
• Southern Michigan Rural ACO
• Suburban Health ACO 2
• Sunshine ACO LLC
• Tar River Health Alliance, LLC
• Texas Rural ACO
• The Premier HealthCare Network LLC
• Winding River ACO

Rural Location AIM encourages ACO development in rural and underserved areas. Of the 45 participants, 36 have at least 65 percent of their delivery sites in rural areas.

Quality of Care: Nine of the current AIM participants also participated in Performance Year 2015 of the Shared Savings Program. All nine ACOs met the required quality performance standards for Performance Year 2015.

Financial Performance: Of the nine current AIM participants who participated in Performance Year 2015 of the Shared Savings Program, two achieved shared savings. These two ACOs generated $15,978,282 in total savings and earned $7,367,396 in shared savings.

Structure of Payments Test 1 (Shared Savings Program Start Date in 2015 or 2016) Under AIM, ACOs that began participating in the Shared Savings Program in 2015 or 2016 receive three types of payments:

• An upfront, fixed payment: Each ACO receives a fixed payment;
• An upfront, variable payment: Each ACO receives a payment based on the number of its assigned beneficiaries; and
• A monthly payment of varying amount depending on the size of the ACO: Each ACO receives a monthly payment based on the number of its assigned beneficiaries.

The structure of these payments addresses both the fixed and variable costs associated with forming an ACO.

Test 2 ACOs (Shared Savings Program Start Date of April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014) Under AIM, ACOs that began participating in the Shared Savings Program on April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014 receive two types of payments:

• An upfront, variable payment: Each ACO receives a payment based on the number of its assigned beneficiaries; and
• A monthly payment of varying amount depending on the size of the ACO: Each ACO receives a monthly payment based on the number of its assigned beneficiaries.

The structure of these payments addresses both the fixed and variable costs associated with making ongoing investments to improve care coordination for existing ACOs.

Recovery of AIM Payments Test 1 ACOs (Shared Savings Program Start Date in 2015 or 2016)

For ACOs that began participating in the Shared Savings Program in 2015 or 2016, CMS will recover payments from earned shared savings for the first two agreement periods that the participant remains in the Shared Savings Program. CMS will recover all pre-payments up to the total shared savings earned by the ACO, but will not pursue amounts in excess of the earned shared savings. Should an ACO not earn sufficient shared savings in the first Shared Savings Program agreement period to fully repay pre-payments, and should the ACO not enter a second Shared Savings Program agreement period, then CMS will not pursue full recovery of remaining pre-payments from that ACO. CMS will pursue full recovery of pre-paid shared savings from any ACO that does not complete its initial Shared Savings Program agreement period or the full term of the AIM agreement.

Test 2 ACOs (Shared Savings Program Start Date of April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014)

For ACOs that began participating in the Shared Savings Program prior to 2015, CMS will also recover payments from earned shared savings for the first two agreement periods that the participant remains in the Shared Savings Program. CMS will recover all pre-payments up to the total shared savings earned by the ACO, but will not pursue amounts in excess of the earned shared savings during the first two Shared Savings Program agreement periods. If the ACO does not earn sufficient savings to repay the AIM pre-paid shared savings during their second Shared Savings Program agreement period, the ACO will be required to repay the outstanding balance directly. CMS will also pursue full recovery of pre-paid shared savings if the ACO terminates before the end of their second Shared Savings Program agreement period.

Eligibility/Selection AIM helps provide support to organizations whose ability to invest in infrastructure and redesigned care processes is improved with additional access to capital.

In order to be eligible for the AIM, an ACO must have met the following criteria:

1. The ACO must be accepted into and participate in the Shared Savings Program. The ACO’s first performance period in the Shared Savings Program must have started in April 1, 2012, July 1, 2012, January 1, 2013, January 1, 2014, January 1, 2015, or January 1, 2016.
2. The ACO has completely and accurately reported quality measures to the Shared Savings Program in the most recent performance year, if the ACO started in the Shared Savings Program in April 1, 2012, July 1, 2012, January 1, 2013, or January 1, 2014.
3. The ACO has a beneficiary assignment of 10,000 or fewer beneficiaries for the most recent quarter, as determined in accordance with the Shared Savings Program regulations, excluding ACOs that start in 2015 or 2016. An ACO that began participating in 2015 or 2016 must have a beneficiary assignment of 10,000 or fewer, unless they are serving a rural area.
4. The ACO does not include a hospital as an ACO participant or an ACO provider/supplier (as defined by the Shared Savings Program regulations), unless the hospital is a critical access hospital (CAH) or inpatient prospective payment system (IPPS) hospital with 100 or fewer beds.
5. The ACO is not owned or operated in whole or in part by a health plan.
6. The ACO did not participate in the Advance Payment ACO Model.

During the selection process, AIM targeted new ACOs serving rural areas and areas of low ACO penetration and existing ACOs committed to moving to higher risk tracks. CMS gave preference to ACOs that provide high quality of care, ACOs that achieved their financial benchmark, ACOs that demonstrated exceptional financial need, and those that submitted compelling proposals for how they will invest both their own funds and CMS funds. Currently, there are no plans to open another application cycle and add more ACOs to this model.

Additional Resources The Innovation Center The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for Medicare, Medicaid and Children’s Health Insurance Program beneficiaries.

Working in concert with the Shared Savings Program, the CMS Innovation Center is testing a number of ACO models and has sponsored learning activities that help providers form ACOs and improve their results. More information on all of these initiatives is available on the CMS Innovation Center website at http://innovation.cms.gov.

More information about the AIM is available on the Innovation Center website at http://innovation.cms.gov/initiatives/ACO-Investment-Model/. Any questions about the program can be directed to AIM@cms.hhs.gov.

For information about the Shared Savings Program, please see: www.cms.hhs.gov/sharedsavingsprogram/.

For Medicare Shared Savings Program ACO Performance Year 2015 results, please visit: https://data.cms.gov/ACO/Medicare-Shared-Savings-Program-Accountable-Care-O/x8va-z7cu.

###