As the July 29 deadline to apply for the 2020 Pathways to Success program looms, providers may be wondering what opportunities and challenges the ACO program presents.
In a July 17 article published in Health Affairs, CMS Administrator Seema Verma said the Trump administration received 206 ACO applications for the July 1 start date of the Pathways to Success program, which requires providers to take on more risk than the previous MSSP program. This means the total number of beneficiaries covered under the program grew from 10.5 million to 10.9 million, she said.
"One of the questions we've gotten a lot in the last year has been around the [belief that] changes CMS made to Pathways to Success appear to be negative in some way, or they may harm us because they're putting more requirements to take on risk," Tim Gronniger, president of Caravan Health, told Becker's. "Since the rule was finalized in December, it's not nearly as bad as everyone else thought. ... It's pretty clear that participation in this program is going to continue to go up this year."
Mr. Gronniger, former chief of staff and director of delivery system reform at CMS, answered Becker's questions about how providers should prepare for Pathways to Success, what barriers they might face and advice on working with the government.
Editor's note: Responses have been lightly edited for clarity and length.
Question: What should providers do before Pathways to Success takes place?
Tim Gronniger: It depends on what they're doing. If they're considering going into the program, then obviously there's a very tight deadline at this point to get the application in. There are still ways to get into the program, though. It always starts with assessing what your organization's needs are, figuring out a plan to address what those needs will be, and putting in place an action plan to make sure that you deliver.
This is a program that has an annual application period at this point. No one who has not thought about this is going to submit their own application by the end of July. But we do recommend that most healthcare organizations be seriously thinking about how they're going to take on risk over the coming years because Medicare is pushing it, private payers are pushing it — avoiding it is not going to be something that is feasible for anybody in healthcare in the long term.
Q: What barriers do you expect providers to face when getting into the Pathways to Success program?
TG: I think the biggest barriers tend to be the same barriers that health systems encounter when they try to do anything. Succeeding in these programs requires significant organizational alignment across different clinics, especially primary care clinics, but also inpatient facilities and outpatient hospital facilities, too. Accepting downside risk for your patients is scary, primarily because these organizations historically haven't had to be responsible for the cost they put on the system.
So getting your head around that and what it means to have PCPs working on patients and then how they transition across the whole system, but also other systems, and being responsible for any spending that those patients generate, requires a whole lot of teamwork, but also matrix management across the big organizations. The management outside and inside of the system is something that health systems always struggle with, and it's particularly acute when you're talking about the full spectrum of care that you're responsible for in this program.
Q: How can providers succeed in Pathways to Success?
TG: If only there was just one thing to do … I think that the most important thing to do is deliver excellent, top-of-license primary care, where you put in place a team-based model that relies heavily on nurses operating at the top of their license, empowering physicians, and providing a lot more holistic, wraparound services for patients to keep them healthy. The difficulty in that is in making ... the finances work as well as all of the supportive services that have to go into that, including technology and analytics, but starting with primary care is something we always recommend for our clients.
Q: With your experience working for CMS, I'm curious if you have any advice for providers on working with the government?
TG: CMS has many detractors in the industry and defenders as well, like me. I think the most important thing to keep in mind when we're working with CMS is that the people on the other end of the phone are really trying to do the best they can to implement the law and regulations, and protect beneficiaries. It's really important that providers participating in the program take seriously their responsibility to follow the rules, to know the regulations, as well as to be good partners for CMS just as any other business partners.
More articles on healthcare finance:
CMS releases proposed home health payment rule for 2020: 7 takeaways
CHS shares close at all-time low
Bernie Sanders pitches $20B hospital bailout plan