Based on feedback from accountable care organizations, consumer groups and other stakeholders, CMS has proposed many changes to the rules governing ACOs participating in the Medicare Shared Savings Program.
There are approximately 4.9 million Medicare beneficiaries assigned to more than 330 MSSP ACOs across the nation. In the first year of the program, 118 MSSP ACOs saved Medicare $705 million, with roughly half of those organizations earning bonuses. However, another 102 ACOs spent more than Medicare's benchmark and one organization was required to repay Medicare, according to Kaiser Health News.
With the risk involved outweighing the opportunity for reward, some organizations withdrew from or threatened to exit the ACO arena. Due to industry outcry, CMS has made a number of proposals aimed at reviving interest in the MSSP. However, there is concern the proposed rules are counterproductive to the underlying principles of ACOs and the MSSP.
Changes to participation agreement renewal and continued participation in Track 1
Currently, MSSP ACOs can participate in shared savings for the first three years without downside risk under Track 1. After the initial 3-year period is up, ACOs can continue in the shared savings program if they enter a performance risk-based track. Under this two-sided track, at the end of each performance year, ACOs must be able to repay any losses incurred within the agreement period. Under current rules, ACOs must be able to document their ability to repay shared losses to CMS to be approved for the two-sided track.
The proposal would alter the process CMS uses to review and approve requests to enter the two-sided track. It would take other factors about the ACO's history into account, including its compliance with shared savings requirements and its ability to meet quality performance standards in the first two years of operation.
The proposal also suggests permitting ACOs an additional agreement period under Track 1 with a lower sharing rate. This means approved ACOs will be able to operate without downside risk for an additional three years, but they will keep a smaller percentage of savings than they did in their first time in Track 1. The lower sharing rate is meant to incentivize ACOs to progress and assume more risk.
Under the proposal, ACOs will only be able to participate in Track 1 again under two conditions. ACOs must have met quality performance standards in at least one of their first two years and they must have not generated losses exceeding the negative minimum savings rate in their first two years in Track 1.
Changes to the beneficiary assignment algorithm
CMS uses a beneficiary assignment algorithm to determine how participating practices receive payments. The algorithm does not determine where the patient can receive care. Rather, it tracks where the patient has already received the most primary care. Beneficiaries are assigned to one practice a year where they receive the most primary care. The algorithm determines which beneficiaries are eligible for reporting on clinical measures and preventive care.
The current procedure assigns beneficiaries in two steps, based on the bulk of primary care services provided by physicians first, and then by specialists, nurse practitioners, physician assistants and certified nurses.
CMS proposed to change the second step of the procedure by removing specific specialists who most likely do not provide primary care and update primary care CPT codes.
CMS also proposed moving primary care services provided by NPs, PAs and CNs to the first step with physicians.
Data sharing modification
Currently, for ACOs to access claims data from CMS, they must first notify beneficiaries and allow them to opt out of data sharing. Participants can do this in one of two ways: They can mail beneficiaries a notification, request the data after 30 days and then follow up with their patient at their next appointment, or they can notify beneficiaries in person at their appointment and request the data immediately.
The CMS proposal aims to streamline this process and reduce confusion for beneficiaries. Given approval, participating ACO providers would put up signs in their practices about data sharing and give patients the information they need if they would like to opt out of data sharing. Patients would directly notify CMS of their data sharing preferences by calling 1-800-Medicare. This would make the process strictly between CMS and beneficiaries.
Proposed changes to financial benchmarks
MSSP ACOs function in 47 states, in addition to Washington, D.C. and Puerto Rico. These ACOs are located in a variety of markets with varying influential environmental factors. However, national fee-for-service expenditures are used in establishing financial benchmarks for MSSP ACOs.
In an effort to make the financial benchmarks reflect regional variations, CMS is looking at new ways of determining whether an ACO has saved Medicare money and is seeking comment on a number of alternative benchmarking approaches.One alternative proposed by CMS is using regional — not national — fee-for-service expenditures.
Some MSSP ACOs have complained they have hit a plateau when it comes to producing savings because efficient practices were already in place when their organizations joined the MSSP. To address this concern, CMS is also soliciting views on making MSSP ACO benchmarks more independent of an organization's past performance and more dependent on its success in being cost efficient relative to its local market.
Creating a new risk-based model
To give MSSP ACOs a chance to earn greater savings than allowed in the existing two tracks of the MSSP, CMS is proposing a new two-sided risk model that would implement elements from the Pioneer program, including higher rates of shared savings.
The new model, called "Track 3" would allow ACOs to keep up to 75 percent of the money they saved Medicare while also being at risk of repaying up to 15 percent of excess spending. The gains and risks associated with the new track are greater than those in existing two-sided MSSP model, which has a savings sharing cap of 60 percent based on quality performance and a loss sharing limit of 10 percent in year three and any subsequent year.
To allow ACOs to focus their improvement efforts, Medicare beneficiaries would be prospectively assigned to ACOs in Track 3, rather than beneficiaries being preliminary assigned to an ACO followed by a retrospective reconciliation.
Modifying minimum savings and loss rates for Track 2
To make Track 2 more attractive for ACOs, CMS is proposing doing away with the current minimum savings and loss rates, which are a flat 2 percent, and making them variable.
CMS is proposing making the minimum savings and loss rates range from 2 percent to 3.9 percent depending on the number of beneficiaries assigned to an ACO.
Modifying MSSP eligibility requirements
An ACO's medical director is required to be an ACO provider/supplier for an ACO to be eligible to participate in the MSSP. To promote flexibility, CMS is proposing doing away with this requirement.
The proposal also contains some potential changes to ACOs' use of health IT. CMS is seeking input on requiring ACOs to describe in their applications to the MSSP how they will "encourage and promote" the use of technology, such as EHRs and analytic tools, for improving care coordination. Under the proposal, a waiver could be issued for certain telemedicine requirements, including the requirement that patients be located in rural areas.
Former National Coordinator for Health IT Farzad Mostashari, MD, told Politico, "The telehealth proposal makes sense and is reasonable." However, he said he's unsure if the proposal will be a "game changer."
CMS is also seeking comment on how to streamline the process for Pioneer program ACOs to apply to participate in the MSSP.