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MACRA Could Spawn Gentler Track for Downside Shared-Savings Risk

Analysis  |  By Christopher Cheney  
   October 24, 2016

A proposal to create a new track in the Medicare Shared Savings Program (MSSP) with limited downside risk is drawing guarded optimism from a pair of healthcare-provider trade associations.

As part of the 2017 final rule announced earlier this month for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), federal officials signaled their intention to create MSSP Track 1+.

Under current regulations, MSSP Track 1 bears no downside risk for accountable care organizations (ACOs); MSSP Track 2 and Track 3 feature both upside and downside risk.

"It is a pretty big jump in terms of downside risk to Track 2; so it would be helpful, particularly to retain ACOs that are already in the program, to give them something in between Track 1 and Track 2," says Melissa Myers, JD, MPA, senior associate director of policy for the Chicago-based American Hospital Association.


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CMS provided few details about MSSP Track 1+ in the 2017 MACRA final rule, with only one paragraph on one page devoted to the proposal in the 1,746-page document.

That paragraph indicates CMS is considering "developing and testing a "'Medicare ACO Track 1+ 'Model" starting for the 2018 performance year".

The Track 1+ Model would test a payment model that incorporates more limited downside risk than in Tracks 2 or 3. CMS envisions Track 1+ as an on-ramp to Tracks 2 or 3. The model could be open to:

  • Track 1 ACOs that are within their current agreement period
  • Initial applicants to the Shared Savings Program
  • Track 1 ACOs renewing their agreement that meet model-eligible criteria

However, until CMS provides more details about MSSP Track 1+, physicians, hospitals, and other ACO stakeholders will have to look to current rules for MSSP and the 2017 MACRA final rule for possible guidance, says Laura Wooster, MPH, interim senior vice president of public policy for the Chicago-based American Osteopathic Association (AOA).

In the 2017 MACRA final rule, CMS pegs the downside-risk cap associated with most Advanced Alternative Payment Models such as MSSP Track 2 and Track 3 at 3% of total-cost-of-care spending benchmarks.


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"If the losses are staggering, you don't owe CMS all the money. It's capped. They don't want to put you out of business," Wooster says. "Reading between the lines, I am going to speculate that the Track 1+ ACO will have a total risk of 3%."

If CMS moves ahead with creating MSSP Track 1+, federal officials should do more than just make the downside risk lower than the levels set in Track 2 and Track 3, say Wooster and Myers.

"If they have any additional adjustments for physician ACOs or additional assistance, that would really help get this going and get more practices interested in getting involved, says Wooster.

"Right now, a lot of ACOs are viewed by physicians as big hospital things that are out of reach or unattainable"."

CMS has put several adjustments and assistance measures in place for shared-savings programs with downside risk, and MSSP Track 1+ should include similar measures, says Myers.

"CMS has made tools available for higher-risk tracks, such as waivers for Medicare payment rules, the geographic limitations on telehealth, and three-day inpatient stay requirement for skilled nursing facility coverage.

"We strongly urge CMS to make those tools available to all ACOs, not just ACOs that have a high level of downside risk"," Myers says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

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