The announcement on Wednesday, January 10 by senior officials at the federal Centers for Medicare & Medicaid Services (CMS) that the agency will require participants in the Medicare Shared Savings Program (MSSP) will be required to submit applications to the new Pathways to Success part of the Medicare Shared Savings Program (MSSP) by February 19, has roiled accountable care organization (ACO) leaders nationwide.
On that same day, the Washington, D.C.-based National Association of ACOs (NAACOS) published a press release criticizing CMS for the timeframe involved, following the issuance of the final rule on December 19. In its Wednesday press release, NAACOS stated that “The Centers for Medicare & Medicaid Services (CMS) late Wednesday announced applications to participate in the new Pathways to Success accountable care organization (ACO) program will be due February 19, two months after the agency published a nearly 267-page rule overhauling the Medicare Shared Savings Program. In response, the National Association of ACOs (NAACOS) is calling on CMS to give ACOs till later in March to understand the complex changes and determine participation options with affiliated doctors, hospitals, and other providers before committing to high-stakes decisions.” And the association quoted its president and CEO, Clif Gaus, Sc.D., as stating that “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. There are too many difficult decisions to rush.”
As Healthcare Informatics Associate Editor Heather Landi noted in her report on the release of the final rule on Dec. 21, the final rule “makes sweeping changes to the Medicare Shared Savings (MSSP) Accountable Care Organization (ACO) program, with the goal to push Medicare ACOs more quickly into two-sided risk models. Referred to as ‘Pathways to Success,’ the Trump Administration’s overhaul of Medicare’s ACO program will redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.
Enough time to prepare to participate?
As NAACOS’s Wednesday press release noted, “CMS on December 21 published the final Pathways to Success rule that dramatically shortens the time ACOs have before being put at risk for repaying losses for not hitting pre-set spending targets. The changes also lowered the financial incentive to participate in no-risk models by cutting the shared savings rate to 40 percent. CMS also established a distinction between so-called ‘high revenue’ and ‘low revenue’ ACOs, forcing high revenue ACOs into risk-bearing models faster. NAACOS, while grateful to the concessions CMS made in the final rule, remains concerned the changes will limit interest in the voluntary program, possibly compel existing ACOs to drop out and overhaul harm Medicare’s largest value-based care program. The MSSP accounts for 561 ACOs, caring for 10.5 million Medicare patients, roughly 20 percent of Medicare,” the association stated.
What’s more, NAACOS noted, “The February 19 deadline applies to new ACOs, ACOs whose agreements expired Dec. 31, 2018, and ACOs who want to end their current agreements and start under the new Pathways structure. ACOs with three-year agreements that expire at the end of 2019 or 2020 are allowed to finish those contracts before starting in the new Pathways structure. After interpreting the effects of the changes, ACOs face several critical decisions, including what groups of doctors and providers to include in their ACOs, signing agreements with those groups (which can number into the dozens), electing levels of risk or track participation, establishing repayment options, making choices about what waivers to apply for, among other choices. On top of those decisions, the deadline to apply for CMS’s Bundled Payments for Care Improvement Advanced Model is March 1. Quality reporting for various Medicare programs is also done in January and February.”
And the NAACOS press release included a statement by an association member leader. "Setting an application deadline two months after publishing the final rule does not give ACOs that have expiring agreements the necessary time to vet the decision internally or the time to process the many elements of the application,” said Jennifer Moore, NAACOS board member and chief operating officer at MaineHealth ACO in Portland, Maine. “Given the significant changes, ACOs need to engage actuaries to understand how we would fare in downside risk. Such an analysis takes time. Without that time, we would have to enter an upside track out of the gate. Further,” Moore said in her statement in the press release, “our ACO has more than 125 tax IDs that need to sign new agreements. On top of that, we must secure a letter of credit (banks indicate that is a six-to-eight week process), evaluate the new waivers, and vet provider and supplier lists,” Moore continued. “I am hopeful that CMS will reconsider this aggressive timeline and balance the need to get started with the understanding that the application process takes planning time."
NAACOS represents “more than 330 ACOs with more than 5 million lives from all 50 states and the District of Columbia formed NAACOS,” according to information on its website.
Shortly after the publication of the NAACOS press release, MaineHealth’s Moore spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the current moment. Below are excerpts from that interview.
Tell me a bit about MaineHealth ACO?
We were formed in 2011, and entered the Medicare Shared Savings Program in 2012. We have 125 tax IDs—it’s 1,500 physicians and nine hospitals. Within the MSSP, we care for 55,000 attributed lives. Altogether, we have 230,000 lives in value-based contracts. We work with 13 different private payers, in addition to Medicare.
How long have you been COO of MaineHealth?
I’ve been COO since that time. We had a predecessor organization; we were a physician-hospital organization before that, so our organization is about 20 years old altogether.
What have been the biggest challenges overall for your organization, in terms of working with all payers?
Speaking broadly, working with 14 different payers and value-based agreements, the variations in payment and methodology are challenging. We’re working to meet the Quadruple Aim, and it’s difficult to work with measures that have less to do with deeper care delivery issues and more to do with different measurement regimens. We have 18 different payer files that we try to assimilate into the same format. When we look at our data and say, look at this population with $300 PMPM and this other population with $500 PMPM, and it can be very hard to tease out from the data a true improvement opportunity versus a function of the data itself. It’s difficult. We have a population health vendor that we contract with to help us aggregate that data and present it to us in various dashboards. We’ve been working with [the Burlington, Mass.-based] Arcadia. And it took us two years to get all of our data into our information system, and it cost a considerable amount.
Does having to manage different contract terms lead to care delivery challenges for clinicians?
We feel very strongly that providers want to treat all their patients in the same way. So we bring forth care delivery and quality opportunities; we try to look at opportunities to improve care for all of our population. The only time I think that that might be a little bit different, is around benefit design. For example, MA—they’ve got a few different bells and whistles; so, for example, this plan can help you pay for your diabetic shoes, for example; but we really try not to make the providers think differently about their care delivery to different types of patients.
Your statement in the press release focused on the paucity of time involved in having to decide how to move forward, based on the February 19 deadline. Can you expand a bit on that?
Certainly. For context, since we were a 2012 start date, beginning in 2017, we started to process with our board the decision as to whether we were going to stay in the program. Under the older rules, we would have had to go into downside risk. And we have nine hospital organizations involved, out of ten hospital organizations. So we spent months considering this. But then they put out the proposed rule in August, and that kind of blew everything up. And then they dropped the final rule the day before everyone was going on holiday. And then we had to quickly scramble even around the notice to apply. So we’ve bifurcated our process, to create a new corporation for the smallest practices, the onesie-twosie practices. They can’t afford to write checks; they struggle even paying our dues. So when the final rule dropped on the 18th, we had to file for a new corporate status, file for a new tax ID for those docs, and use Milliman to help us understand what was in the rule. So actually, we will probably have to change our strategy. We saw that in the final rule, we realized we could implement the original strategy that we had developed. We have 125 onesie-twosie practices, so we can’t wait to learn our actuarial results are; we may have to scramble and split our network. Of our 55,000 members, we’ll put 30,000 into a downside track. So of the 1,500, about 800 would stay upside; on a PCP basis, a majority are employed. So the majority will be in the downside part of the program, which was called Track 1 Plus, which would be Track E. But now we don’t have time to do that; we’d have to wait for the analysis from Milliman.
Given that, have you and your colleagues decided what you’ll do, based on the just-announced February 19 deadline?
We’re just learning this today, so I don’t know that we have many options. Even our bank told us yesterday they wanted to start a process with them. It’s a lengthy and costly processing time to do a letter of credit. So we’ll probably all have to go back to Level B, which is upside-only, and forget about downside, because we just don’t have the time we need.
In other words, on a basic level, CMS is not providing adequate time, then?
That’s right. Two cohorts—the 2012 starts had a hard stop at the end of 2018, because they have to make a decision by 7/1/19; they have to decide. And other groups that are just starting out. In fact, one group in our current MSSP had planned to split off and go their own way, but they won’t have time now. Those who didn’t have a hard stop at the end of 2018 and still have another year to decide what to do, won’t be as dramatically affected.
There were definitely some complexities facing providers in the December 21 final rule.
That’s right. They [CMS officials] could have given us more time on the application side. Now, I understand where they’re coming from—they need to run the numbers and set up their benchmarks for July 1, so they’re hitting us. It’s unfair to us. And I recognize that of the 111 or so ACOs that started in 2012, we’re one of the bigger ones. Not everybody has the 125 tax IDs that we have. And we wanted to move into downside, but they’re really eliminating our ability to do that in 2019. That’s so disappointing for us. We’re really trying to stay engaged in the process, because from a cultural perspective, we think it benefits us. And it helps get and keep our physicians engaged in the work.
