Medicare Compliance & Reimbursement

Hint: CMS wants ACOs to ramp up their risks.

If you’re considering joining an Accountable Care Organization (ACO) in 2019, you may want to wait until CMS finalizes its new proposed rule on the Medicare Shared Savings Program (MSSP). Guidance suggests ACOs will have a lot more to balance if the swaps and additions are a go — and following the new rules may prove challenging.

Background: In August, CMS released a revamp of its MSSP called “Pathways to Success,” which tones down one-sided risk models while promoting two-sided ones, putting more onus on the ACO to improve performance and increase risk (see related story, p. 129). The proposed rule was published in the Federal Register on Aug. 17, 2018.

Here are five changes that may come to fruition if the MSSP proposed rule is finalized:

• Reduce and revise Track options. The proposed rule cuts the number of Tracks to two titled “Basic and Enhanced.” Basic will replace Tracks’ 1, 1+, and 2 with a gliding system and a “gradual shift to risk,” which “includes five levels [A-E], with a one-sided model available only for the first two years to eligible ACOs,” explains the National Association of ACOs (NAACOS) in a release on the proposal. The Enhanced Track takes over the Track 3 spot and is a two-sided model for ACOs willing to accept greater risk and looking for greater financial reward.
• Clarify Advanced Alternative Payment Model (APM) qualification. According to the proposed rule, only ACOs in the Basic Track’s fifth year, level E, would qualify to participate in an Advanced APM under the Quality Payment Program (QPP). Enhanced Track ACOs automatically qualify for Advanced APMs.
• Increase accountability. ACOs will have to show improvement and measure it against their local peers. The proposals “update the benchmarking methodology to incorporate regional trends from the start of an ACO’s participation in the MSSP,” notes national law firm Robinson & Cole LLP in analysis in its blog, Health Law Diagnosis.
• Pay the patients. After a physician explains to the patient that he is part of an ACO and what that means, “CMS proposes to allow certain ACOs under performance-based risk to provide incentive payments to patients for taking steps to achieve good health,” states the fact sheet.
• Promote and integrate other new Medicare policies. As part of its quality focus, CMS plans to include MyHealthEData Initiative principles with the requirement of 2015 Edition Certified EHR Technology (CEHRT), mentions the MSSP proposal. Meaningful Measures and Patients Over Paperwork get a nod as the number of quality measures to report is slimmed down from 31 to 24, reducing providers’ administrative burdens.

Note: For a more indepth read of the MSSP proposed rule in the Federal Register, visit www.federalregister.gov/documents/2018/08/17/2018-17101/medicare-program-medicare-shared-savings-program-accountable-care-organizations-pathways-to-success.