On August 9th, 2018, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule change to the current Medicare Shared Savings Program (MSSP) structure. Along with updates to the tracks that are available to Accountable Care Organizations (ACOs) through the program, a number of new features and methodologies would be introduced under the new rule. These new aspects are intended to help ACOs innovate and be successful in care coordination, promote beneficiary engagement, encourage program integrity, and improve care.
The proposed rule would introduce an updated benchmarking methodology for ACOs. Currently, the benchmarking methodology only incorporates regional Fee for Service (FFS) expenditure trend factors when an ACO is on their second or subsequent 3-year agreement period. Under the new rule, the regional factors will be applied to all of the agreement periods, which will become 5 years in length. Additionally, benchmarks can be adjusted in either direction up to 3% during an agreement period in order to reflect changes in the population’s health status.
ACOs will be given the option for each performance year whether they want prospective member assignment or preliminary prospective member assignment with a retrospective reconciliation. Currently, the methodology is determined based on the track that an ACO is enrolled in. There will also be other changes to the beneficiary assignment methodology. The definition of primary care service will be expanded, and beneficiaries may be given the option to opt in to an ACO. Additionally, voluntary alignment would continue to be allowed and allowing the member to designate any physician regardless of specialty.
Beginning January 1, 2020 ACOs would also potentially be eligible to have participating physicians receive payments for using telehealth services. Physicians of ACOs that are in a 2-sided agreement with prospective assignment would be eligible for this. Additionally, use of the SNF 3-day waiver would be expanded to apply to any ACO in a 2-sided arrangement and to critical access hospitals and small rural hospitals part of these ACOs, and 2-sided ACOs could provide incentive payments up to $20 to beneficiaries for each related primary care service they receive.
Under the proposed rule, CMS would provide additional resources and features to the program. Beyond the track structure change that would occur, various aspects will be updated, including new benchmark calculations and support of ACO programs. For more information about the proposed rule and the various aspects involved, see the article found here (link).
The new rule proposed by the Centers for Medicare & Medicaid Services (CMS) on August 9, 2018 would result in significant changes to the way the Medicare Shared Savings Program (MSSP) works for new Accountable Care Organizations (ACOs) and those currently in a one-sided risk model. Under the current program, ACOs can enter the MSSP under an upside-only risk arrangement referred to as a Track 1 ACO for up to two three-year agreement periods. After that time the ACO is required to transition to a two-sided risk agreement or exit the program. However, the proposed rule would end the Track 1 program and replace it with a new five-year agreement called the BASIC track. This new track would transition from one-sided to two-sided risk throughout the agreement period. This change has the potential to significantly impact ACOs that were planning on entering the MSSP or renewing in Track 1 for their second agreement period by exposing them to two-sided risk earlier than expected.
The proposed BASIC track would consist of five levels that gradually increase the amount of risk and reward taken by the ACO. The first two levels, called “Level A” and “Level B” are identical one-sided models designed to allow new ACOs to establish themselves and gain familiarity with the program. Levels A and B are structured similarly to the current Track 1 program. After that there are three two-sided risk levels with progressively increasing amounts of risk and savings potential, called “Level C”, “Level D”, and “Level E”. Level E is similar to the current MSSP Track 1+ program, while Levels C and D have lower shared risk and savings potential. Each year, the ACO is automatically moved up one level in the progression until reaching Level E, where it would remain until the end of the five-year agreement period. The ACO can also choose to move into a higher level in the progression in any given year; however, once an ACO has moved up the automatic progression continues from its newly-selected level– the ACO cannot reverse or stop the progression. The only level an ACO can remain in for more than one year is Level E at the end of the progression, where the ACO would remain until the expiration of the five-year agreement.
Whether an ACO can enter into the BASIC track, and where they are eligible to enter, depends on its makeup and history in the MSSP. New ACOs are eligible to enter the BASIC track at Level A. New ACOs are defined as those where fewer than 50 percent of its participating physicians have recent experience as part of a Track 1 ACO. Current Track 1 ACOs and re-entering ACOs, those where greater than 50 percent of the participants have recent experience in a Track 1 ACO, are eligible to enter the BASIC track; however, they are required to enter at Level B. This restricts more experienced ACOs to a single year of one-sided risk as opposed to the two years that new ACOs can choose. The ability to renew into the BASIC track for a second agreement period depends on if the ACO is determined to be high or low revenue. Low-revenue ACOs can enter a second BASIC agreement period limited to Level E only. High revenue ACOs are required to move up to the ENHANCED track or exit the program at the conclusion of their first agreement period. Low revenue ACOs also have a lower loss sharing limit. More information about what qualifies an ACO as high or low revenue can be found here.
The proposed changes to the MSSP program have the potential to significantly impact both existing ACOs and those considering entering the program. For more detailed information on this proposed rule and its potential impact please click here.
On August 8, 2018, the Centers for Medicare and Medicaid Services (CMS) released a sweeping proposed regulation that, if enacted, will significantly change the Medicare Shared Savings Program (MSSP). The proposed regulation, titled “Pathways to Success,” accelerates the path for accountable care organizations (ACOs) to participate in shared risk arrangements while simultaneously softening key provisions, allowing lower revenue ACOs to participate with reduced total financial risk.
Currently the MSSP is composed of four different tracks, all with different shared saving and shared loss structures, that ACOs can enter into for a three-year agreement period. Under the proposed rule, there would be two different tracks: BASIC and ENHANCED each with a five-year agreement period. Under the BASIC track, there are five different levels with various risk and reward levels that ACOs transition through during their five-year agreement period. These various levels range from a one-sided risk model to a model that closely aligns with the current Track 1+. The new ENHANCED track is largely the same as the existing Track 3.
In addition to these new tracks, the proposed rule affects other key program provisions. There will also be a variety of new features available to ACOs through the proposed rule. ACOs will be able to choose every year whether to receive prospective assignment or preliminary prospective assignment with retrospective reconciliation. Additionally, beneficiary incentive programs, expanded telehealth services, and three-day SNF rule waivers will be supported for ACOs who are in two-sided risk arrangements under the new tracks.
If approved, the rule proposed by CMS would go into effect on July 1, 2019 for a one-time six-month performance year that would aid in the transition. For more information about the proposed rule, reference the articles found here.