MSSP Stakeholders Share Concerns with CMS

CMS encouraged to toss out proposals in the rule that 'would likely result in significant decrease in MSSP participation.'

Key stakeholders in the Medicare Shared Savings Program warn that the Centers for Medicare & Medicaid Services efforts to improve the program may actually dampen participation.

In a letter this week to CMS Administrator Seema Verma, AHA Executive Vice President Thomas P. Nickels said the hospital lobby "appreciates certain steps CMS is taking to improve the stability and flexibility of the MSSP" by embracing telehealth to expand access.

"However, we are concerned that, as a whole, the proposals in the rule would likely result in significant decrease in MSSP participation," Nickels said.

"While such an outcome may very well be CMS's expectation, it unfortunately disregards many of the lessons we have learned from the current program," he said.

The stakeholders' remarks were submitted ahead of yesterday's midnight deadline for comments on the proposed final rule. 

Specifically, Nickels said CMS should not go forward with the proposed differentiation of participation options for high- and low-revenue ACOs. Instead, he said CMS should improve program methodology to reward improved quality and reduced costs. 

He also urged CMS to allow new MSSP ACOs three years in upside-only risk, rather than two, with an option to move into downside risk sooner if they choose. 

"Evidence demonstrates that per beneficiary savings correlate to experience, especially after ACOs' third year in the MSSP," Nickels said.

"Drastically shortening the length of time in which they can participate in an upside-only model, along with attempting to create arbitrary differentiations between physician- and hospital-led ACOs, does not empower ACOs to maximize their contribution to patient care and is not a pathway for improving the value of the MSSP for beneficiaries," he said.

American Medical Association Executive Vice President James L. Madara, MD, in a 10-page letter to Verma this week, provided a detailed list of recommendations on the proposed rule.

Among AMA's more than two dozen recommendations, CMS was urged to:

• Extend ACO agreement periods to five years, as this will improve stability and predictability for ACO participants.
   
• Retain the Track 1 model, potentially with modifications to encourage greater savings, instead of forcing all ACOs into two-sided risk models.
   
• Raise proposed sharing rates for new ACOs because the proposed rates are too low.
   
• Exclude ACO payment incentives under the Merit-based Incentive Payment System (MIPS) from ACO expenditures for purposes of comparing benchmark to actual spending and calculating each ACO’s savings and losses.

Incentives 'untenable' for new ACOs

The AHA and AMA recommendations were consistent with the findings of a recent poll by the National Association of ACOs, which found that 60% of ACOs would have been unlikely to have entered MSSP under the revised policies proposed by CMS.

Clif Gaus, president and CEO of NAACOS, said ACOs are ready to work with CMS to improve MSSP "without inadvertently forcing ACOs and providers to remove themselves from the bipartisan goal of lower-cost, higher-quality care."

"NAACOS believes that ACOs should take on risk," Gaus said in a media release. "But the speed of CMS's proposed path to risk and the agency's proposal to significantly cut financial incentives will make participation in this voluntary program untenable for new ACOs."

Specifically, NAACOS urged CMS to:

• Reverse a proposal to reduce the shared savings rate from 50% to 25% for ACOs in shared savings only or low risk models. NAACOS said shared savings rates should be 50% for Basic Levels A and B, 55% for Basic Levels C and D, and 60% for Basic Level E.
   
• Allow ACOs entering the program to remain in a shared savings-only model for four years with an additional fifth year available for those that demonstrate superior performance.
   
• Make no distinction between high- and low-revenue ACOs. The proposed 25% threshold of ACO participant revenue as a percent of total ACO spending for the assigned population appears arbitrary and creates division where none should exist.
   
• Finalize the proposal to enact extended, five-year agreement periods to provide more program stability and predictability.
   
• Finalize proposals to more gradually introduce risk and to permanently include the current Track 1+ Model in the MSSP (renamed Basic Level E), creating a smoother glide path to risk.
   
• Allow risk adjustment to change by +/-5% over an agreement period, rather than the proposed +/-3%, to reflect risk changes so ACOs are fairly judged on performance without being unfairly expected to manage a population's increasing disease burden.

Gaus said one survey respondents noted that the proposal put forward CMS make sense when looked at in isolation, but that the proposed revisions in their entirety create barriers to entry or continuation for most ACOs.