House Reps Want to Extend MSSP Track 1 ACO Participation

May 22, 2018 - Seven House Representatives are calling on CMS to allow successful accountable care organizations (ACOs) in the Medicare Shared Savings Program’s (MSSP) Track 1 to continue in the upside-only financial risk track for a third agreement period.

The MSSP requires Track 1 ACOs to transition to another track that contains downside financial risk after two three-year agreement periods. 2019 will mark the first time that CMS will force Track 1 ACOs into another track with downside financial risk or ask the organizations to leave the program.

“Most of these ACOs are simply not ready to take on risk, and compelling them to do so is not realistic given that MSSP performance data is only available for years 2013-2016 and the capital required to participate in a two-sided risk model can reach into the millions,” contended Congress members Suzan K. Delbene (D-WA), Erik Paulsen (R-MN), Earl Blumenauer (D-OR), Terri Sewell (D-AL), John Lewis (D-GA), and Mike Thompson (D-CA).

House Representative Patrick Meehan (R-PA) also cosigned the letter to CMS Administrator Seema Verma before stepping down from office shortly after its publication.

The Congress members warned CMS that forcing the Track 1 ACOs that started during the MSSP’s inaugural year (2012/2013) to take on risk or quit the program would jeopardize the initial successes of the value-based purchasing transition.

READ MORE: Exploring Two-Sided Financial Risk in Alternative Payment Models

“Moving successful ACOs out of Track 1 may have the negative effect of pushing providers back to the fee-for-service model and could significantly harm the MSSP, as well as our overall movement toward value-based payment models that help deliver higher quality care at a lower cost,” they wrote.

CMS should acknowledge that successful upside-only ACOs have taken on some financial risk by making investments in care quality and spending improvements.

ACOs invest an average of $1.6 million each year to advance care coordination and maintain operations, the House Representatives said citing a 2016 National Association of ACOs (NACCOS) study. These investments also go into human capital, including employing data analysts, case managers, care coordinators, and practice transformation specialists, who all work together to pinpoint, create, and implement care pathways.

“This critical work, however, is not reimbursed by CMS,” the letter to the federal agency stated. “The significant investment in activities that are not reimbursable is in itself taking on risk. If Track 1 ACOs decide to leave the program, these investments will be lost.”

Those investments are also more likely to be lost because of Track 1 ACOs deciding to leave the program. A recent NAACOs survey of Track 1 ACOs that must assume downside financial risk at the end of the year found that 71 percent of the organizations are considering leaving the program rather than take on downside financial risk.

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

But CMS can sustain the successes of upside-only ACOs that have generated savings, earned top quality scores, and demonstrated consistent progress toward program goals by allowing them to continue in Track 1 for another three-year agreement period, the House Representatives argued.

“Extending the Track 1 participation beyond two agreement periods is a commonsense action CMS can take to continue to hold the line on Medicare spending while improving quality for seniors,” they wrote. “We encourage you to take swift action on this matter to prevent ACOs from fleeing the MSSP before performance year 2019.”

CMS is also under pressure to extend MSSP Track 1 participation from six healthcare industry groups. NAACOS, American Medical Association (AMA), Premier Healthcare Alliance, and other associations urged the federal agency in February 2018 to allow successful Track 1 ACOs to continue in the upside-only risk track for another agreement period.

“These ACOs need more time to prepare for two-sided risk,” the industry groups wrote. “While six years may sound sufficient, given the programmatic changes and considerable learning curve for these ACOs, this is not enough time.”

The groups also argued that limited available data also challenged upside-only ACOs with taking on downside financial risk.

READ MORE: Accountable Care Organizations Grow, But Face New Challenges

CMS should allow Track 1 ACOs that have either realized net savings across four performance years, scored at least in the 50th percentile in quality for of the three pay-for-performance years, or improved overall quality scores by at least 10 percentage points during the pay-for-performance years to stay in upside-only risk track.

But CMS may not be willing to wait for the upside-only ACOs to prepare for downside financial risk assumption. In a recent speech at the American Hospital Association’s Annual Membership Meeting, CMS Administrator Seema Verma explained that while the federal agency understands “systems need time to adjust, our system cannot afford to continue with models that are not producing results.”

She specifically pointed to upside-only ACOs when discussing models that are not producing results.

“A subset of ACOs has taken on significant downside risk,” she said. “These ‘two-sided ACOs’ have shown significant savings to the Medicare program while advancing quality. And we applaud this success and support the boldness of providers that participate in these models.”

“However, the majority of ACOs, while receiving many waivers of federal rules and requirements, have yet to move to any downside risk. And even more concerning, these ACOs are actually increasing Medicare spending, and the presence of these ‘upside-only’ tracks may be encouraging consolidation in the marketplace, reducing competition and choice for our beneficiaries.”

The likelihood that CMS grants the policymakers and industry groups their request to extend MSSP Track 1 participation may be a stretch. But the federal agency has yet to respond to the recommendations from both parties.