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MSSP Final Rule 'Small Step in the Right Direction', Says NAACOS

Analysis  |  By Christopher Cheney  
   June 13, 2016

The National Association of Accountable Care Organizations is generally disappointed with the final rule for the Medicare Shared Savings Program, but sees a couple of positive changes, the nonprofit said Friday.

The 2017 final rule "is a small step in the right direction, but there's still a long way to go in terms of improving the MSSP overall," says Allison Brennan, vice president of policy for NAACOS.

Highlights of the 2017 MSSP final rule, which was released last week, include significant changes to how the Centers for Medicare & Medicaid Services set the spending benchmark that draws the line for earning shared savings and inducements for ACOs to take on two-sided risk.

MSSP features three-year agreements between CMS and ACOs. Healthcare providers have the option to pick one of three tracks in the shared savings program.

Track 1, which has been the most popular option since MSSP was launched in 2012, has upside risk only. Track 2 and Track 3 have both upside and downside risk.

Brennan says one of the 2017 final rule's main inducements for ACOs to assume two-sided risk—allowing an ACO to stay in Track 1 for a fourth year before switching to Track 2 or Track 3—is underwhelming.

"I don't think the policy with the additional fourth year in Track 1 will have a significant impact in incentivizing the ACOs to take on two-sided risk. "

"The current two-sided risk models do not appeal to most ACOs," she says. "We see about 90% of ACOs remaining in Track 1. Also, it's important to keep in mind that ACOs that want to continue in Track 1 have the ability to do so for six years; so, by giving an ACO an additional fourth year, it's not really a needle-mover."

Related: 56% of ACOs Would Quit MSSP if Ineligible for MACRA's APM Bonus

NAACOS had asked for CMS to "finalize a policy that would allow ACOs at the start of any performance year to enter into a new period agreement under a two-sided risk model," says Brennan.

"That's a better option because it allows for the same shift to two-side risk but it also allows for additional opportunities for ACOs who are in the middle of an agreement period."

She says the biggest step forward is in the way CMS will be rebasing the MSSP benchmark at the end of the three-year contracts to increasingly reflect regional spending trends rather than rebasing the benchmark exclusively on historical performance.

"The main positive element is the acknowledgement that… eventually, ACOs are not going to be able to always keep improving on their past performance."

Incorporating the regional expenditure data into the rebased benchmarks allows ACOs to be judged in part based on their historical performance, and increasingly relative to the other providers in their area.

"We're really pleased that they went in this direction, it's something we have been advocating for quite some time," Brennan says.

She is less pleased that CMS missed at least two opportunities to make significant improvements in MSSP.

"We had requested that for the regional reference population, CMS exclude ACO-assigned beneficiaries. And the reason we asked for that was that it allows for a cleaner comparison between the ACO and fee-for-service providers in its region."

The other change that NACCO asked for and did not get, "was for CMS to continue to account for savings from prior agreement periods when the agency rebases the benchmarks."

Essentially, that means that by not accounting for the savings that the ACO produced, their benchmark is lowered.

"Adding back the savings into the rebased benchmark essentially helps them by not continuing to penalize them for doing a good job in the past. It goes back to the diminishing law of returns; because every time they have significant savings, then their benchmark is reduced, so they have to keep beating that," Brennan says.

If CMS is going to achieve significantly higher MSSP enrollment in two-sided risk models, the agency is going to have to offer more inducements than are present in the 2017 final rule for the program, she says. NAACOS' position is more fully detailed here.

Christopher Cheney is the CMO editor at HealthLeaders.

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