MSSP Flexibility Vital to Future of Value-Based Care

Proposed changes to the fledgling Medicare Shared Savings Program would create a path for growth of the ACO model, but there's more work ahead.

Proposed changes to the Medicare Shared Savings Program (MSSP) would create steps toward the program's growth, but the Center for Medicare & Medicaid Services has more work ahead to refine the ways it will benchmark performance going forward.

Failure to do so could snuff the life out of the fledgling MSSP program, which includes fewer than 500 total members, but represents nine out of every 10 ACOs.

That's the claim of 22 organizations, including the American Medical Association, Medical Group Management Association, American Medical Group Association, American College of Physicians, and various specialty societies that signed a joint letter to CMS Acting Administrator Andy Slavitt on March 25.

Although the groups support the transition to regional benchmarks, they asked CMS to revisit several details. "While we recognize and appreciate CMS's efforts in this notice of proposed rulemaking to improve program methodologies to retain and attract [accountable care organizations] ACOs, we emphasize the critical need for the agency to further modify the program to address other critical issues such as quality measurement, risk adjustment and unstable assignment to ensure a successful future for this program," they write.

Expansion from One-Size-Fits-All
If CMS takes these comments to heart, the implications would be substantial, according to Suzanne Falk, MGMA associate director of government affairs.

"The program right now just isn't having the kind of numbers behind it to justify expanding it, which is what CMS is trying to do as we move toward an alternative payment model environment," she says. In 2014, about a quarter of Track 1 ACOs earned shared savings, she notes, and nearly half generated losses.

"These benchmarking changes are really critical and they do definitely improve by incorporating in those regional cost data, creating a more accurate picture. But they're still sticking with kind of that one-size-fits-all approach that misses the mark. And because the program is voluntary, we really need that to be flexible in order to attract new and different types of ACOs," Falk says.

The abridged recommendations of the MGMA and other groups to CMS include the following:

• Finalize, with modification, blending ACO historical and regional cost data into ACO benchmarks
• Provide ACOs with maximum flexibility and choices related to transitioning to benchmarks that comprise a component of regional cost data
• Focus on comparing ACO performance relative to fee-for-service Medicare by excluding ACO assigned beneficiaries (for all ACOs in the region) from the regional beneficiary population
• Honor the current policy that accounts for savings in rebased benchmarks, rather than punish ACOs that worked hard to earn savings in previous agreements
• Modify and enhance the proposal to reopen ACO determinations to include greater opportunities for ACOs, especially when CMS errors are the cause, and shorten the timeframe from four to two years

Overall, these requests urge CMS to be less aggressive and more flexible in the way it implements new benchmarks. Because of the considerable investment of time and money involved in becoming an ACO, medical groups need assurance that the effort will be worthwhile.

Upping Participation and Retention
To boost participation, "we really need to incorporate flexibility in the way that they approach and reward different types of savings, whether that's improving on past savings or just being a consistent low spender relative to your region or nation," Falk says.

"What they really need to do is create a pathway to recognize past savings specifically, and to incorporate more flexibility into the benchmarking overall."

These elements are also integral to preventing more MSSP dropouts, according to Yul D. Ejnes, MD, a past chair of the ACP board of regents and member of a Rhode Island MSSP group practice. While the general premise of moving to regional benchmarks should help high-performing groups continue to achieve incentives, he notes that the nuances need to be friendlier for smaller players as well.

"The dropout rate is a concern," Ejnes says, especially given that some of the ACOs that have dropped out are groups that are known to provide high-value care. So that if the model can't work for them, how's it going to work for some of the less able groups?"

A MACRA Must
Perhaps one of the biggest factors for healthcare organizations contemplating participating in the MSSP is whether these ACOs will qualify as an alternative payment model under MACRA, the Medicare Access and Children's Health Insurance Program Reauthorization Act.

Though the question is not addressed in CMS's proposed rule, the commenters explicitly call on the agency, in their letter, "to allow physicians participating in all MSSP ACOs to qualify for MACRA APM incentive payments, provided they meet the threshold levels of revenue or patient participation required by the law."

Ejnes and Falk agree that this provision is a must.

"We're all kind of waiting on the edge of our seats here for the proposed rule that deals with the implementation of MACRA," Falk says. On behalf of MGMA members on the fence in deciding whether being part of an ACO will benefit them, the group is sending a firm message to CMS: "Given how large a component the MSSP is to the ACO program, you really need to incorporate that as qualified APMs under MACRA or you're going to totally just kick the wind out of the sails of the entire ACO program," Falk says.