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AMA, AHIP, and Others Oppose Upside-Only ACO Changes for MSSP

Shortening the amount of time upside-only accountable care organizations (ACOs) have to assume downside financial risk threatens the sustainability of the MSSP, nine industry groups said.

Upside-only accountable care organizations (ACOs) and the Medicare Shared Savings Program (MSSP)

Source: Thinkstock

By Jacqueline LaPointe

- The American Medical Association (AMA), Medical Group Management Association (MGMA), and Health Care Transformation Task Force (HCTTF) are among nine industry groups calling on CMS to reconsider proposed changes to the Medicare Shared Savings Program (MSSP).

Proposals to shorten the time new ACOs have to assume downside financial risk from six to two years and reduce the shared savings rates for upside-only ACOs by half would jeopardize the sustainability of the largest Medicare ACO program, argued the coalition, which also includes the National Association of ACOs (NAACOS), Premier, Association of American Medical Colleges (AAMC), American College of Physicians (ACP), America’s Essential Hospitals, and American’s Health Insurance Plans (AHIP).

“Our recommendations reflect our unified desire to see the MSSP achieve the long-term sustainability necessary to enhance care coordination for Medicare beneficiaries, lower the growth rate of healthcare spending and improve quality in the Medicare program,” the groups recently wrote to CMS Administrator Seema Verma.

“Program changes that deter new entrants would shut off a pipeline of beginner ACOs that should be encouraged to embark on the journey to value, which is a long-standing bipartisan goal of the Administration and Congress and important aspect of the Quality Payment Program,” the groups continued.

CMS proposed to overhaul the MSSP in August 2018 to promote downside financial risk assumption in the Medicare ACO program.

READ MORE: For Ongoing ACO Shared Savings, Look Outside Inpatient, Primary Care

The MSSP has grown from just 27 ACOs when the program launched in 2012 to 561 ACOs covering 10.5 million beneficiaries in 2018. The Medicare ACO program may have significantly expanded, but the majority of participating organizations (82 percent) are still in the program’s basic, upside-only financial risk track.

“After six years of experience, the time has come to put real ‘accountability’ in Accountable Care Organizations,” Verma stated when announcing the proposed MSSP overhaul. “Medicare cannot afford to support programs with weak incentives that do not deliver value. ACOs can be an important component of a system that increases the quality of care while decreasing costs; however, most Medicare ACOs do not currently face any financial consequences when costs go up, and this has to change.”

Verma proposed to make the change by reducing the flexibilities and benefits available to upside-only ACOs in the new MSSP, which would be renamed Pathways to Success.

However, the AMA, MGMA, NAACOs, and other industry groups in the coalition disagreed, arguing the proposals would actually force more ACOs to quit the voluntary Medicare program.

MSSP ACOs are already averse to mandatory downside financial risk adoption. A spring 2018 survey conducted by NAACOs revealed that over 70 percent of MSSP ACOs that must assume downside financial risk by 2019 per program rules were likely to quit the MSSP. The organizations did not want to be forced to assume downside financial risk.

READ MORE: Key Issues Impacting Two-Sided Risk Accountable Care Organizations

Finalizing the proposals to accelerate the downside financial risk timeline and reduce the shared savings rate to just 25 percent for upside-only ACOs would jeopardize the future of the MSSP, which is saving Medicare money and improving care quality, the coalition contended.

CMS recently reported that MSSP ACOs saved about $314 million and about 34 percent of the organizations earned shared savings bonuses in 2017.

Another recent analysis by Dobson DaVanzo & Associates also uncovered that MSSP ACOs saved Medicare about $1.84 billion from 2013 to 2015 and reduced Medicare spending by $542 million after accounting for shared savings bonuses.

At the same time, the ACOs improved care quality scores. MSSP ACOs subject to pay-for-performance measures earned a mean quality score of 90.5 percent out of 100 percent, according to data from 2017, the most recently completed performance period.

A 2017 HSS Office of the Inspector General (OIG) report also found MSSP ACOs have achieved high quality scores since the program’s launch and the organizations have even made progress on key measures, including hospital readmissions and screening beneficiaries for risk of falling and depression.

READ MORE: Provider Engagement Key to Accountable Care Organization Success

Proposed changes to the MSSP could threaten the care quality and Medicare spending improvements generated by the ACOs, which are primarily upside-only organizations, the recently formed coalition stated.

Other industry leaders have expressed similar concerns with the proposed changes to the MSSP’s upside-only risk track.

The American Hospital Association (AHA) opposed the proposals, arguing the shortened downside financial risk assumption timeline does not account for the time and experience needed for ACO success.

“The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances,” the association’s Executive Vice President Tom Nickels stated in August 2018. “Hospitals and health systems must build upon their current infrastructure, which entails forming new and different contractual relationships and incentivizes successful strategies.”

“While some have already taken significant steps toward achieving such alignment, others are not as far down this path,” he added. “A more gradual pathway is critical for hospitals and health systems that are interested in participating in risk-bearing models – particularly those that are exploring such models for the first time.”

Leaders of the House Committee on Ways and Means also recently voiced concerns with the proposed MSSP overhaul.

“As you consider stakeholder comments on this proposal, we ask that you bear in mind one impactful issue all ACOs and healthcare providers must weigh in judging participation in this program and taking on risk: stability,” wrote Representatives Kevin Brady (R-TX) and Peter Roskam (R-IL). “As new contracts for shared savings arrangements are drawn up, we ask that a component of these negotiations include some level of regulatory and payment stability for the length of the agreement across all aspects of Medicare.”

However, industry experts on the other side of the debate argue that the shorter glide path to downside financial risk assumption and the lower shared savings rate for upside-only ACOs will be the kick organizations need to mature in the program.

Aledade CEO and former National Coordinator for Health IT at HHS Farzad Mostashari notably tweeted that moving to downside financial risk helps to “weed out ACO squatting.”

The comment period on the proposed MSSP overhaul rule ends on Oct. 16, 2018, after which CMS is expected to finalize proposals to modify the large Medicare ACO program.


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