Is the Discourse Over the MSSP Program Teetering Towards Potential Conflict?

Sept. 24, 2018
The joint statement by nine associations challenging CMS Administrator Seema Verma around her plans to insert more rigor into the MSSP program, feels like a teeter-totter moment for CMS

Things appear to be heating up quickly in the interactions between the senior leaders at the Centers for Medicare and Medicaid Services (CMS) and the leaders of some of the accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) for ACOs.

As Healthcare Informatics Managing Editor Rajiv Leventhal noted in a just-published report, The National Association of ACOs (NAACOS) and eight other healthcare stakeholder groups have sent a letter to the Centers for Medicare & Medicaid Services (CMS), expressing concerns about the federal agency’s proposed changes to the Medicare Shared Savings Program (MSSP). In August,” he noted, “CMS proposed sweeping changes to the MSSP, by far the largest federal ACO model, with 561 participants. At the center of the proposed rule, called “Pathways to Success,” is a core belief that ACOs (accountable care organizations) ought to move more quickly into two-sided risk payment models so that Medicare isn’t on the hook for money if the ACO outspends its financial benchmarks.”

Further, as Leventhal noted, “Specifically, CMS is proposing to shorten the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years. This proposal, coupled with CMS’ recommendations to cut potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs—will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny. NAACOS, comprised of more than 360 ACOs across the U.S., is one association that has been actively pushing back on the CMS proposal. The group believes that ACOs need, and deserve, more time in one-sided risk models since it takes years to develop the necessary infrastructure to be successful. What’s more, NAACOS is of the belief that one-sided risk ACOs actually save far more money than CMS gives them credit for.”

Appropriately, then, considering their offense at CMS’s proposed changes, “NAACOS and others—including the American Medical Association (AMA), Medical Group Management Association (MGMA), and Premier—said in a press release accompanying the letter to CMS that the proposed Pathways to Success program would create several positive changes and includes a number of improvements the value-based community has previously recommended.”

Nor did their press release statement emerge out of a vacuum; indeed, CMS Administrator Seema Verma has become increasingly vocal about her frustrations with the MSSP program in recent months. As Associate Editor Heather Landi noted in a report, in late August during a webinar sponsored by the Accountable Care Learning Collaborative, Administrator Verma spoke in very firm terms about her insistence that ACOs in the MSSP program move forward with alacrity to take on two-sided risk. “I think many people recognize that it’s time to take that next step and it’s time to evolve the program; it’s been six years,” she said on August 27. “We also understand that there may be providers that are not ready. But, our focus is to work with providers that are serious about making the investments and providing better care for lower cost.” And, she added, “I think the experience that we’re seeing is that there are some providers that don’t take a few years to transition, and have come into the program right away, taking full risk, so we know that this is possible. After six years, there is a lot of experience out there and we can learn from one another as far as best practices.”

Statements like those have been deeply concerning to many ACO leaders—thus Thursday’s joint statement. “The ACO community wants to help CMS work through other issues in the rule which, if finalized as proposed, would have unintended consequences of undermining the broader shift to value-based care,” the leaders wrote yesterday. “Specifically, we are very concerned with shortening the time new ACOs have in a shared savings only model from six to two years and cutting in half the shared savings rates for these ACOs from 50 percent to 25 percent. This is especially concerning because a spring 2018 survey showed that over 70 percent of ACOs facing mandatory risk for 2019 were likely to leave the program as a result of being forced to assume financial risk. When analyzing the recent performance year 2017 MSSP results, it shows that Track 1 ACOs achieved more savings per beneficiary than ACOs in the two-sided MSSP models. We request that CMS modify these proposals for all ACOs in the final rule, to allow more time for ACOs in a shared savings only model and to apply a shared savings rate of at least the current 50 percent.”

As the leaders noted, “The MSSP remains a voluntary program, and it’s essential to have the right balance of risk and reward to continue program growth and success. Program changes that deter new entrants would shut off a pipeline of beginner ACOs that should be encouraged to embark on the journey to value, which is a long-standing bipartisan goal of the Administration and Congress and important aspect of the Quality Payment Program.”

What’s more, the membership of this ad hoc group is in many ways as important as the content of their letter to CMS. In alphabetical order, they are: the Association of American Medical Colleges; American College of Physicians; America’s Essential Hospitals; America’s Health Insurance Plans; American Medical Association; Health Care Transformation Task Force; Medical Group Management Association; NAACOs; and Premier Inc.

What’s more, these groups represent a spectrum of stakeholders around the landscape of ACO evolution, including health insurers (AHIP), physicians in practice (AMA), medical group executives (MGMA), integrated health systems (Premier Inc.), and even medical colleges (AAMC). So their open letter to CMS is one that Administrator Verma and all the senior officials at the agency should consider very carefully.

As I said in a blog written after Verma made her comments in that webinar last month, and referring to Health and Human Services Secretary Alex Azar, Administrator Verma, and National Coordinator for Health IT Donald Rucker, M.D., “[I]t seems to me that Azar, Verma, and Rucker, and their colleagues, are in a bit of a challenging place here, because even as the progress has been measurably stronger in the Next Gen ACO program compared with that in the MSSP program, even in Next Gen, it hasn’t been spectacular. Meanwhile, Verma’s attempts to push down harder on the levers of payment and regulation in order to turbocharge ACOs, could very easily backfire, causing more ACOs to leave the MSSP program than to switch to two-sided risk.”

So we find ourselves at an excruciatingly delicate moment now in this “dialogue” between the leaders of ACOs and Administrator Verma. And this thing could “tip” in any direction. I would hope that Administrator Verma and her fellow CMS officials would take into consideration as they plan their next moves, anticipated to involve adding more rigor into the MSSP program. A careful balance will be required in order to avoid alienating perhaps the majority of ACO leaders, while still pushing the program forward. In any case, with regard to this entire subject, as we say in the news business, stay tuned.

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