October 22, 2018

What providers like—and don't like—about CMS' proposal to overhaul MSSP

Daily Briefing

    Health care providers have offered a mixed response to a proposed rule that would overhaul the Medicare Shared Savings Program (MSSP) and accelerate accountable care organizations' (ACOs) transition to two-sided risk models, MedPage Today reports.

    Slide deck: Everything you need to know about the proposed MSSP overhaul

    Proposed rule details

    MSSP encourages ACOs to cut health care costs and improve care coordination by enabling participating ACOs to receive bonus payments if they maintain high-quality care while decreasing Medicare spending compared with their individual benchmarks. The program currently offers three participation tracks that allow ACOs to take on varying amounts of risk.

    Currently, there are 561 ACOs participating in MSSP, and 82% are in Track 1 of the program, which is the only MSSP track that does not require providers to take on two-sided, or both "upside" and "downside," risk. Under MSSP, ACOs can stay in the upside-only risk track for up to six years.

    However, CMS' proposed rule, called "Pathways to Success," would reduce to two years the amount of time ACOs could stay in MSSP without assuming risk. The proposal would do so by replacing MSSP's existing three tracks with two new tracks:

    • The BASIC Track, which would move participants to a two-sided risk model after two years; and
    • The ENHANCED Track, which would require participants to take on downside risk in year one.

    Both tracks would have five-year contract terms and require participants to take on downside risk, effectively eliminating CMS' upside-only Track 1 option. 

    CMS also proposed allowing ACOs deemed "low revenue," such as those made up of physician practices, to participate in the BASIC track for two agreement periods. ACOs deemed "high revenue," such as hospital-based organizations, would be required to advance to the ENHANCED track after completing the BASIC track.

    The agency projected the changes would save $2.24 billion over ten years if the proposed rule is finalized, and that more than 100 ACOs would drop out of MSSP.

    CMS accepted public comments on the proposed rule until Oct. 16.

    Health care providers split on proposed rule

    In comments submitted to CMS, a few health care providers expressed support for some of the proposed rule's provisions, but many raised concerns and provided recommendations on how CMS could improve the proposal.

    For example, some industry groups said they supported the agency's proposal to move toward a two-track program that would let providers gradually assume financial risk and become comfortable with penalties as they learn to navigate the new regulations. 

    In addition, James Madara, executive vice president and CEO of the American Medical Association (AMA), in a comment wrote that AMA is "pleased … CMS proposes to extend ACO agreement periods to five years, as this will improve stability and predictability for ACO participants." Madara noted, "Studies of physician experience with payment models have found that constant changes in payment policies and requirements are extremely disruptive to practices."

    Similarly, the National Association of ACOs (NAACOS) in a comment wrote, "Many ACOs have expressed the desire to have more program stability and predictability and shifting to longer agreement periods will enable that."

    However, a recent NAACOS survey found 61% of 127 ACOs, which represented 23% of ACOs currently participating in MSSP, opposed the proposed rule. Those ACOs expressed concerns about the proposed rule's provisions to:

    • Decrease how long ACOs can go without assuming financial risks; and
    • Reduce the amount ACOs receive in shared savings at the beginning of the program.

    The American Medical Group Association (AMGA) in a comment recommended CMS lengthen the time ACOs can go without assuming financial risk to three years. AMGA also wrote that CMS could "improve program benchmarking to correct for current weak financial incentives" and discontinue the use of historical spending to reset subsequent agreement period benchmarks. AMGA recommended CMS update benchmarks annually after the first performance period.

    The American Hospital Association (AHA) in a comment wrote that the proposed rule "as a whole … would likely result in significant decrease in MSSP participation," and recommended that CMS extend the length of time ACOs can go without assuming financial risk to three years.

    AHA also wrote that CMS should not adopt different standards for high- and low-revenue ACOs, arguing that CMS provided "inadequate justification" for the assumption that hospital-led or high-revenue ACOs are able to assume financial risk at a faster pace than physician-led or low-revenue ACOs.

    AHA recommended that CMS instead improve the MSSP methodology "to accurately reward performance for improving quality and reducing costs and offer resources and assistance to all ACOs." AHA added that CMS should consider changes to MSSP's benchmarking methodology.

    America's Physicians Group (APG) in a comment wrote that proposed reductions in how long ACOs can go without assuming risk and in bonuses for meeting benchmarks would require ACOs to provide a significant upfront investment. APG wrote, "The current levels proposed are not sufficient to encourage new organizations to join the program. The costs and risks of forming and maintaining an ACO are significant; the rewards should be high enough to offset those deterrents" (Gooch, Becker's Hospital Review, 10/17; Colliver, "Pulse," Politico, 10/17; Frieden, MedPage Today, 10/17; Clason, CQ News, 10/16 [subscription required]).

    Next, learn how the Medicare ACO models stack up

    Hospitals, health systems, and physician groups across the country continue to evaluate the menu of Medicare ACO options. Whether applying for the first time, graduating to downside risk, or tracking CMS's evolving approach to ACOs, leaders need to understand the key details of each model.

    Download this infographic to learn how the different Medicare ACO models stack up.

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