Healthcare providers say proposed changes to Medicare's most popular accountable-care payment program are financially underwhelming and accelerate the initiative to an overly aggressive pace.
In public comment letters filed on proposed changes to the Medicare Shared Savings Program, many providers say MSSP faces an existential threat if the rule changes are not revised.
A joint comment letter signed by nearly three dozen healthcare provider organizations, including the American Medical Association, the American Academy of Pediatrics, the Medical Group Management Association, the Association of American Medical Colleges and the National Association of ACOs, is highly critical of the proposed changes.
"While the MSSP program has generated strong interest, sustained and increased participation hinges on the potential financial opportunities being adequate to support the investments needed to improve care and, ultimately, create a program that is sustainable for the long term," the providers say in their joint comment letter.
"First-year MSSP performance data from November 2014 showed that slightly more than half of participating ACOs (118/220) reduced costs enough to generate savings to the Medicare program. However, only about half of these (58) were able to meet the minimum savings threshold required to actually share in the savings. Thus, overall, only 26% of MSSP ACOs received a shared savings payment from Medicare. As currently designed, the MSSP program places too much risk and burden on providers with too little opportunity for reward in the form of shared savings."
In his comment letter, David Gross, the executive director of Morristown, NJ-based Atlantic ACO, laments proposed changes to Track 1 of MSSP, which features gain sharing with no downside risk. He says two of the proposed rule changes are particularly onerous: barring MSSP Track 1 participation to providers that have not reached the minimum saving threshold for at least one year and reducing the shared saving rate from 50% to 40%.
"The proposed requirement that continued participation by existing ACO participants in Track One of the MSSP must have achieved shared savings within the [Minimum Savings Rate] corridor in one or both [of the first two 'performance years'] would prohibit an ACO such as ours from participation despite a positive trend on many measurable performance criteria," Gross wrote.
While Atlantic ACO has yet to cross the minimum savings threshold to qualify for gain sharing payments, the organization has met MSSP quality standards set by the Centers for Medicare & Medicaid Services. "Our quality indicators as measured by CMS have consistently been at or better than national MSSP performance averages across most categories of performance. Quality trend improvement in the attributed population should be an alternative to the MSR savings threshold of performance."
Atlantic ACO officials "strongly urge" CMS to reinstate the 50% shared savings level for Track 1 MSSP participants, Gross wrote. "This erosion of the opportunity to achieve a 50% shared savings will erode the opportunity of the ACO to recoup development and operating costs and impair the ACO's ability to appropriately reward member physicians. It is a significant disincentive in moving our physician members to a value-based system of care delivery."
Gross says Atlantic ACO and its hospital partners are at risk of squandering $10 million of MSSP-related investments, and says that that softening the proposed changes to Track 1 of MSSP is "critical to our continued participation in the 2016 Medicare Shared Savings Program."
The comment letter from Rick Pollack, executive VP of the American Hospital Association, scolds CMS for crafting MSSP in a way that "applies too many 'sticks' and offers too few 'carrots' to participating providers" in the program.
"While some of CMS' proposed improvements are welcome and could make the program more attractive to new applicants and existing ACOs, we question whether other proposals go far enough to correct misguided design elements that emphasize penalties rather than rewards," Pollack wrote.
CMS, AHA contends, is moving too quickly in tightening standards for providers in MSSP Track 1, asking federal official to "balance the risk versus reward equation in a way that encourages ACOs to take on additional risk but does not penalize ACOs that need additional time and experience with the MSSP before they are able to do so."
'The Risk of Driving Providers out of the Program'
In separate recent interviews, AAMC and AMA officials said CMS needs to be more responsive to providers' concerns over MSSP to help ensure the success of Medicare's drive to accelerate value-based payment reforms.
"If ACOs are going to continue, we have sought improvements, including maintaining Track 1 and not diminishing the business case to continue participation in it," said Janis Orlowski, MD, chief healthcare officer at AAMC.
Orlowski says CMS is pushing providers too quickly toward participating in the proposed Track 3 for MSSP, which features both upside and downside risk. "Under the proposed rules, providers need to move into two-sided risk in Track 3 or lose money," she said. "CMS is pushing to diminish the attractiveness of Track 1, but they run the risk of driving providers out of the program."
Providers are willing to work with CMS to develop MSSP and other payment reforms that help move Medicare away from the fee-for-service payment model, but many are fearful of the financial consequences of moving too quickly, Orlowski says. "We want to play, but we don't want to take on a downside risk before we know exactly how the program works."
Barbara McAneny, MD, a New Mexico-based oncologist and chair of the AMA Board of Trustees, says the vast majority of physician practices operate as small businesses that are wary of fundamental changes to payment models.
"With any of these new payment programs, more flexibility is a good thing. If you've seen one physician practice, you've seen one. Physician practices are as unique as the communities they serve," she said. "We also need to make sure that small practices with four or five physicians have a safety net, so they can continue to do their core business and start trying the new services associated with value-based care."
MSSP Concerns Stretch Further Than Financial Sweetening
The joint comment letter signed by nearly three dozen healthcare provider organizations raises several concerns about the proposed MSSP rules beyond clear-cut financial incentives to participate in the program.
"The Department of Health and Human Services (HHS) recently stated a goal of tying 30% of fee-for-service Medicare payments to alternative payment models, such as ACOs, by the end of 2016, and tying 50 percent of such payments to alternative payment models by 2018," the providers wrote.
"In order for HHS to meet its goals and ensure continued and enhanced participation in the MSSP, we urge CMS to strengthen the assignment of Medicare beneficiaries, establish a more appropriate balance between risk and reward, adopt payment waivers to eliminate barriers to care coordination, modify the current benchmark methodology, and provide better and timelier data."
The window for the public to file comments on the proposed MSSP rule changes closed Feb. 6.
Christopher Cheney is the CMO editor at HealthLeaders.