Medicare Compliance & Reimbursement

Get ready to transition over to the new program ASAP.

 Accountable Care Organizations (ACOs) take on risks to promote provider cooperation and innovation while saving both the patient and Medicare money. However, CMS suggested that some ACOs weren’t risking as much as they should to reap the rewards of the program — enter a completely redesigned Medicare Shared Savings Program (MSSP).

Background: In August, CMS released an MSSP proposed rule with the overhaul catchphrase,“Pathways to Success,” which suggested numerous changes aimed at improving ACOs’ outcomes. The final rule, published in the Federal Register on Dec. 31, 2018 and tweaked to adopt the public’s input, isn’t any rosier than the original proposals. Though providers might find the streamlined policies embrace efficiency, the downside of increased risks with less chance of incentive remain. The final rule is slated for implementation on Feb. 14, 2019, according to agency guidance.

Why the Changes Now?

The reasoning for the MSSP final rule is related to Medicare’s move to strengthen its value-based system, “not just because we want to,” but to thwart the “unsustainable trajectory” healthcare spending is on, suggested CMS Administrator Seema Verma in a blog post. “The rule strikes a balance between encouraging participation in the ACO program and advancing the transition to value, ultimately protecting taxpayers and patients”

Verma added, “Medicare can no longer afford to support programs with weak incentives that do not deliver value. As we structure new payment arrangements, the impact on the overall market will be top of mind.”

Stats: According to the National Association of ACOs (NAACOS), 10.5 million Medicare Fee-for-Service (FFS) beneficiaries are cared for through Medicare ACOs. “The MSSP accounts for 561 ACOs… roughly 20 percent of Medicare,” noted a NAACOS release.

The new MSSP policies will save the agency $2.9 billion over ten 10 years, CMS estimates. Moreover, the agency believes forcing ACOs to take on increased financial risks sooner rather than later will translate to better, more informed quality care, insisted Verma.

But industry reps don’t agree. Notwithstanding some “concessions,” the final rule changes will impede MSSP progress and “compel existing ACOs to drop out and overhaul harm Medicare’s largest value-based care program,” NAACOS warned (See key points below).

Fast-Paced Implementation Vexes Industry Insiders

Not everyone is pumped up about the MSSP revamp despite the feds’ elation and promises. While some feel the turnaround time is too quick — ACOs that want to participate in “Pathways to Success” must apply by Feb. 22, 2019, with a July 1, 2019 start date — others refer to the time restraints of the upside-only model and the punishing financial risks.

NAACOS consternation: “ACOs barely have time to understand the new rules, and organizing an application is very complicated and for some it is now a high-risk decision,” said Clif Gaus, ScD, NAACOS president and CEO in a release about the rule. “There are too many difficult decisions to rush.”

AHA frustration: “Today’s final rule will not be helpful in the move toward value-based care,” cautioned Tom Nickels, executive vice president of government relations and public policy for the American Hospital Association (AHA) in a prepared statement on the final rule. “We remain opposed to CMS drastically shortening the length of time in which ACOs can participate in an upside-only model. Hospitals and health systems have asked for a more gradual pathway because building a successful ACO that is able to take on financial risk requires significant investments in time, effort and finances.”

Resource: Read the MSSP final rule at www.federalregister.gov/documents/2018/12/31/2018-27981/medicare-program-medicare-shared-savings-program-accountable-care-organizations-pathways-to-success.