The Trump Administration has been saying for months it is committed to improving value in health care. This month, talk has turned into action. The new Medicare Shared Savings Program (MSSP) payment rule by the Centers for Medicare and Medicaid Services (CMS) shows the administration is serious and is doubling down on two-sided risk-bearing payment models that encourage accountability for financial and health outcomes. The proposed rule would:
- Convert the current MSSP tracks into a new "glide path" to increasing risk under two new BASIC and ENHANCED tracks,
- Establish a later start date and longer participation agreement period, and
- Make other programmatic changes, including changes to benchmarking and beneficiary alignment methodologies and the availability of waivers and beneficiary incentives.
As with lower MSSP tracks today, the BASIC track would allow for an on-ramp to risk, but still offers the least attractive option in terms of opportunities to more meaningfully improve care, reduce costs and share in savings. Furthermore, only ACOs in the ENHANCED track (formerly MSSP Track 3) and Level E of the new BASIC track (formerly MSSP Track 1+) can qualify as advanced alternative payment models for the purposes of MACRA payment incentives. Public comments on the new rule are due October 16, and the rule will be finalized later this year.
So, what should ACOs be considering now?
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Thou shalt not ignore the July 1 start date option. You can do this--Don't miss out! Even ACOs that just started an MSSP contract can re-up on July 1, 2019 under the new proposed rule, which may be an advantageous strategy for ACOs with regionally-efficient physician networks. Since the inception of the MSSP, ACOs have had to compete against their own historical performance, leading to unrealistic benchmark targets for those already delivering high quality, low cost care. Benchmarks will now incorporate a regional component for all ACOs starting or renewing on July 1. ACOs should invest in understanding their historical cost position in their market as they make important strategic decisions related to network composition, Track selection, and renewal timing.
- You’re eight months late! (But there’s still time to protect your benchmark next year.) New proposed risk-adjustment factor (RAF) rules would mean benchmarks can go up or down by up to three percent. Hierarchical Condition Category (HCC) scores would be based on encounters in the calendar year preceding the performance year (for example, 2018 scores would impact 2019 RAF), so it will be important to gather the best possible data on the risk in your patient population this year. Now is the time to build ACO capabilities necessary for success, including RAF, care management, and actuarial analysis and projections. Organizations will need to develop a risk game plan: educating their Boards and physicians, determining organizational risk appetite, exploring re-payment mechanism options, and developing clinical, operational and financial risk mitigation strategies.
- Don’t overthink it: Be a Pro! CMS has proposed letting MSSP ACOs choose their preferred alignment mechanism: prospective (such as in the Next Generation ACO program or current MSSP Track 3 model) or prospective alignment with retrospective reconciliation (as in the current Track 1 approach) annually. Prospective alignment is still better for ACO leaders wishing to meaningfully impact clinical outcomes, manage their networks and maximize shared savings.
- Got an ACO “elevator pitch?” CMS is also exploring the idea of introducing a “hybrid assignment” approach that would be a mixture of modified claims-based assignment (for beneficiaries with seven or more primary care visits with ACO participants), voluntary alignment to a provider and direct beneficiary “opt-in” to an ACO. The proposal would expand the rules for voluntary alignment, meaning that any ACO can recruit any Medicare beneficiary into their network. Don't want others poaching your ACO's beneficiaries? It's time to get smart on, and good at, outreach and communications strategies. The opt-in-based alignment methodology would allow beneficiaries to align directly to the ACO rather than with a specific participating provider. CMS says it will monitor the program not only on its ability to reduce health care costs and improve quality but also on whether the program “provides beneficiaries with the value and choice demonstrated by other Medicare options such as Medicare Advantage.”
- Don’t forget about Direct Provider Contracting (DPC). Earlier this year, CMS solicited input on ways to test a direct provider contracting (DPC) model. The DPC model would involve agreements between payers and primary care or multi-specialty groups in Medicare Parts A and B, Medicare Advantage and Medicaid. This model is still in development but is anticipated to hit the scene this fall and may introduce some of the most attractive elements of Medicare Advantage to the fee-for-service space, such as the option for increased financial accountability and open-market competition for beneficiaries. Will the timeline for enrollment align with the new July 1 MSSP start date? Will the model preempt the continuation of other successful models or adversely fragment the market? Evolent continues to weigh in with CMS, and we hope engaged ACOs are doing the same.
Stay tuned for our assessments of the opportunities and relative return-on-investment of DPC and other CMMI models as they emerge as part of the Center’s “New Direction” portfolio.
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More Content by Ashley Ridlon
