Shouldn’t CMS Officials Be More Straightforward About ACOs’ Level of Progress? Sorting through the Jumble of Numbers for Clarity

Oct. 4, 2016
CMS’s August 25 release of the latest numbers on the progress of ACOs in the MSSP and Pioneer ACO programs was clouded by the framing and presentation coming from the agency itself. Couldn’t CMS officials have been more transparent and straightforward about all of this?

As HCI Managing Editor Rajiv Leventhal noted in his news article on Thursday, senior officials at the federal Centers for Medicare & Medicaid Services (CMS) yesterday lauded the progress of accountable care organizations (ACOs) participating in both the Medicare Shared Savings Program (MSSP) for ACOs and the Pioneer ACO program.

The announcement itself began thus: “The Centers for Medicare & Medicaid Services (CMS) today released the 2015 quality and financial performance results for Medicare Accountable Care Organizations (ACOs) that show that ACOs continue to improve the quality of care for Medicare beneficiaries, while generating financial savings. As the number of Medicare beneficiaries served by ACOs continues to grow, these results suggest that ACOs are delivering higher quality care to more and more Medicare beneficiaries each year. According to the results,” the CMS announcement stated, “over 400 Medicare ACOs generated more than $466 million in total program savings in 2015, accounting for all ACOs’ experiences. Of these, 125 qualified for shared savings payments by meeting quality performance standards and their savings threshold. The results show that more ACOs are sharing savings in 2015 compared to 2014 and that ACOs with more experience in the Pioneer ACO Model and the Medicare Shared Savings Program tend to perform better over time.”

But, as Leventhal pointed out in his article, after doing some analysis of the statistics, the reality is that “Although more than 400 Medicare accountable care organizations (ACOs) generated more than $466 million in total program savings in 2015, nearly seven in 10 of those ACO organizations did not generate enough savings to receive bonuses, according to an Aug. 25 announcement from the Centers for Medicare & Medicaid Services (CMS).

As Leventhal noted, “According to the just-released CMS data, 125 of the 404 total federal ACOs qualified for shared savings payments by meeting quality performance standards and their savings threshold. The results show that more ACOs are sharing savings in 2015 compared to 2014 and that ACOs with more experience in the Pioneer ACO Model and the Medicare Shared Savings Program (MSSP) tend to perform better over time. However, similar to last year, many of these ACOs did not produce enough savings to earn bonuses.”

Meanwhile, he also noted, of the 12 remaining ACOs in the Pioneer ACO program, which began with 32 ACOs in 2012, and is down to 12 now, eight of the ACOs generated savings last year, six of them generating enough savings to earn shared savings back to their organizations; meanwhile, only one of the four ACOs in the program had to pay money back to the Medicare program. Not a super-great set of outcomes, but not a bad set of outcomes, either.

So what are the top-line financial and clinical outcomes measures from both programs? With regard to financial savings, 119 of the 392 MSSP ACOs, or 30 percent, generated shared savings, while six of the 12 Pioneer ACOs, or 50 percent, generated shared savings. And, as CMS officials reported in their announcement, “83 ACOs had health care costs lower than their benchmark, but did not qualify for shared savings, as they did not meet the minimum savings” requirements. Meanwhile, “An increasing proportion of ACOs have generated savings above their minimum savings rate each year. For PY15, 31 percent of ACOs (120 of 392) generated savings above their MSR compared to 28 percent (92 of 333) in PY14 and 26 percent (58 of 220) in PY13.” And, CMS officials noted, “ACOs with more experience in the program were more likely to generate savings above their MSR [minimum savings requirement]. For performance year 2015, 42 percent of ACOs that started in 2012 generated savings above their MSR, compared to 37 percent of 2013 starters, 22 percent of 2014 starters and 21 percent of 2015 starters.”

Meanwhile, when it comes to quality outcomes, CMS officials noted Thursday that “Shared Savings Program ACOs that reported quality in both 2014 and 2015 improved on 84 percent of the quality measures that were reported in both years. The average quality performance improved by over 15 percent between 2014 and 2015 for four measures: screening for risk of future falls, depression screening and follow-up, blood pressure screening and follow-up, and providing pneumonia vaccinations.” Further, they added, “Over 91 percent of ACOs in a second or third performance year during 2015 increased their overall quality performance score through Quality Improvement Reward points in at least one of four quality measure domains.”

As for quality outcomes among the Pioneer ACOs, CMS officials noted that the mean quality score among Pioneer ACOs increased to 92.26 percent in the fourth year from 87.2 percent in the third year. The mean quality score has increased in every year of the model, with a total increase of over 21 percentage points since the first year. Of the 12 Pioneer ACOs, nine had overall quality scores above 90 percent for the fourth year, with scores ranging from 92.59 percent to 98.38 percent. What’s more, quality performance improved considerably from 2014 to 2015 and across all four years of the Pioneer ACO Model. Overall quality scores for nine of the 12 Pioneer ACOs were above 90 percent in the fourth year. All 12 Pioneers improved their quality scores from 2012 to 2015 by over 21 percentage points, according to the CMS data.

What does it all mean?

So—what does all this mean? There are two broad issues we should consider here. One is the overall results from these programs—and the other is how CMS officials are managing the process of communicating about those results.

First, in terms of the overall outcomes from both programs, while the financial results are far from spectacular—202 of the total 192 MSSP ACOs (as of current 2016 data, there are 433 MSSP ACOs), or 52 percent of that total cohort, generated some level of savings in 2015 (though only 119 received checks for having exceeded the minimum savings targets set for them by CMS), and eight of the 12 Pioneer ACOs did so, with six of those eight exceeding their minimum savings targets—they aren’t disastrous, either. Indeed, one might say that if half of the total ACOs (not including the ACOs participating in the new Next Generation ACO program) are achieving some level of savings, then one could argue that the two programs are at about the correct level of rigor, since if nearly all were doing so, it would appear that the financial savings benchmarks had been set too low. Meanwhile, if almost none of the ACOs in either program were meeting their goals, one would almost certainly have to conclude that the financial savings benchmarks had been set too high.

Meanwhile, the quality outcomes are laudable, with “over 91 percent of ACOs in a second or third performance year during 2015 increased their overall quality performance score through Quality Improvement Reward points in at least one of four quality measure domains.” On the Pioneer side, nine of the 12 had overall quality scores about 90 percent for their fourth year of participation.

Looking at all of these topline outcomes, one would have to say that things, while slogging along somewhat, are certainly not on any disastrous path, in either program; instead, they are within a reasonable range of expectations, given the programs’ parameters and “ages” at this point.

But there are two nagging questions here. The first is, why aren’t there more patient care organizations participating in either program? Participation in the Pioneer ACO Program is tiny, with only 12 ACOs out of the original 32; and though the MSSP program is far larger, 433 is still a small number, relative to the overall cohort of patient care organizations in the U.S. healthcare system that could theoretically be participating in it. So when will larger numbers join? Perhaps more will end up going into the Next Generation program, which started out with 21 participating organizations back in January.

The other question has to do with why CMS officials continue to try to present the latest results in the “sunniest” light possible. If one reads the announcement itself and then digs a bit into the numbers, it is clear that CMS officials have very carefully framed the latest results, as they did repeatedly last year. One can see why they might do so; on the other hand, could it be a mistake to try to “prettify” things, when ultimately, the reality of the results is what it is?

If one were to be asked to advise CMS officials, one might offer this: wouldn’t it be better for them to acknowledge, perhaps even underscore, how challenging it is to participate in all of these ACO programs? CMS officials could then fairly congratulate the leaders of all the participating ACOs for making the progress they’ve been making, rather than underplaying the difficulties involved in participation. That would be my thought, anyway, were anyone to ever ask me.

Because this ACO journey is inevitably going to be a long, complex one, and one with no shortcuts. And if CMS officials want their agency to be seen as a strong partner to healthcare providers on the journey into the new healthcare, then taking on more of a cheerleader stance about these programs might be smart strategy in the long run—or even in the short and medium runs.

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