Decision Health’s Part B News recently featured quotes from Vytalize Health Executive Vice President and National Medical Director John Torontow and Chief Business Officer Gary Thompson in an article about Shared Savings. Read the original article here.
By: Roy Edroso, Part B News
Published Nov. 14, 2022
By finalizing most of its proposed changes to the Medicare Shared Savings Program (MSSP), CMS is giving massive breaks to new and low-revenue accountable care organizations (ACO) that serve underserved communities, as well as enticements for others to stay. The agency evidently wants to bulk up enrollment, and some experts think it’s worth a try.
The new deal for new entrants who meet targets associated with CMS’ “health equity” goal of better care for such beneficiaries can be generous, including a one-time upfront payment of, potentially, hundreds of thousands of dollars, as well as quarterly bonuses over a two-year term.
MSSP is the mothership for Medicare-sponsored ACOs. Its mix of no-risk, low-risk, and high-risk tracks, titrating the amount of bonus earnings such organizations can gain by saving CMS money on care of beneficiaries as well as the money they can conceivably lose if they fail to deliver such savings, has by both measures been a success since its inception in 2012.
According to an April 2022 CMS accounting, the program has “483 ACOs with over 525,000 participating clinicians serving more than 11 million Medicare beneficiaries.” And it is delivering savings; a recent CMS report found it had spent $1.7 billion less in 2021 than the agency calculates it would have spent otherwise, making it “the fifth consecutive year the program has generated overall savings and high-quality performance results.”
For a while, CMS was pushing for MSSP ACOs to take on more risk, as seen in its Trump-era Pathways to Success program (PBN blog 8/23/18). But then the program began to exhibit issues with recruitment and retention; other programs appeared to be drawing prospective entrants away, and many new entrants had trouble adjusting to even the most modest requirements of the program (PBN 9/13/21).
The biggest boost comes from Advanced Incentive Payments (AIP) that will go to “low revenue ACOs that are inexperienced with performance-based risk new to the Shared Savings Program and that serve underserved populations.” Such ACOs will be eligible for a “one-time fixed payment of $250,000 and per beneficiary quarterly payments for the first 2 years of an ACO’s 5-year agreement period,” the final rule states.
To be considered for the upfront payments, ACOs need to submit a supplemental application and proposed spending plan; possible quarterly payments will be based on the ACO’s beneficiaries’ status under Medicare Part D low-income subsidy (LIS) metrics and/or Medicare and Medicaid dual eligibility, or “the ADI national percentile rank of the census block group” where beneficiaries live.
“CMS is determined to get all traditional Medicare patients into an accountable care relationship by 2030,” says Dave Halpert, chief, client team of Roji Health Intelligence, a consultancy, and data registry in Chicago. “But the number of ACO participants has plateaued, and the number of patients in underserved communities is proportionately smaller than the nation at large.”
Hence, the payments. “These will be critical, as startup costs are frequently cited as a significant barrier to entry in the ACO market,” Halpert says. “By tying the magnitude of these payments to the number of patients who are dually eligible or reside in a high deprivation area, these AIPs will increase ACO participation, the number of beneficiaries cared for in ACOs and, specifically, to encourage ACO development in communities that are underrepresented in the existing ACO world.”
Even if they don’t qualify for the upfront bonuses, new entrants with no prior shared-savings experience could be eligible to stay in a one-sided shared savings model for five years, rather than being pushed into double-sided risk after a few years as is currently the case. That would allow new entrants “more time to invest in infrastructure and redesigned care processes for high quality and efficient health care service delivery.”
John Torontow, M.D., MPH, executive vice president and national medical director of Vytalize Health, a consultancy to ACOs in Hoboken, N.J., thinks the changes will significantly lower barriers to entry.
“By giving ACOs more time to advance to greater risk, CMS will encourage more independent physicians to join the program,” he says, “Making health equity a specific goal of the Shared Savings Program and then backing it up by bolstering ACOs that provide high-quality care to underserved patients will allow for more Medicare patients to take advantage of the care coordination that is the promise of advanced primary care.”
Gary Thompson, Vytalize’s chief business officer, predicts similar benefits from the added assistance to ACOs that treat beneficiaries with multiple chronic conditions in underserved areas or populations with a high concentration of dual-eligibles.
These ACOs get one more major perk: they’re eligible for a “health equity adjustment” that adds as much as 10 points to their quality performance score if they report all-payer electronic clinical quality measures (eCQMS)/MIPS CQMs, are high performing on quality, and serve a high proportion of underserved beneficiaries. The adjustments go up based on the volume of beneficiaries from underserved communities the ACO serves.
There are some breaks as well for MSSP ACOs who may not qualify for these extraordinary perks.
For example, for MSSP ACOs that are taking on risk, the “sliding scale” that was in effect before 2021 for determining whether ACOs met the performance requirements for recouping savings these ACOs is coming back.
CMS expressed its “concerns that the current structure of the quality performance standard creates a cliff of ‘all-or-nothing’ scoring where an ACO may be ineligible to share in savings due to a minor difference between its MIPS Quality performance category score and the quality performance standard required to share in savings at the maximum sharing rate for the applicable performance year,” according to the final rule.
An ACO that does not meet the quality performance standard but is reporting at least three eCQMs or MIPS CQMs can have its savings share calculated by multiplying a figure derived from its MIPS Quality performance category score based on those CQMs, two claims-based measures calculated by CMS, and its CAHPS for MIPS survey score, by the (regular) sharing rate for the ACO’s track.
It bears remembering as well that, insofar as they pick up beneficiaries from underserved communities, older ACOs can get in on some of the largesse laid out for new ACOs. For example, they are eligible for the aforementioned health equity adjustment to their performance score if they report three eCQMs/MIPS CQMs and the CAHPS for MIPS survey and have beneficiaries from underserved groups.
The eCQMs/MIPS CQMs proposed reporting method will not become mandatory for Shared Savings ACOs until 2025. Ambitious ACOs that choose to do so voluntarily now get a scoring break: They only need to achieve a 30th percentile benchmark on one eCQM/MIPS CQM measure, rather than in all the benchmarked measures reportable under CMS Web Interface, the popular reporting method that eCQMs/MIPS CQMs will replace (PBN 11/15/21).
Both are technically electronic CQMs; the “short version” of the difference between them, Halpert says, is that one is reported by registries rather than directly by the provider. “They’re calculated slightly differently,” he says. “But CMS is looking at the same type of information from one version to the next. The MIPS CQMs offer qualified registries a bit more latitude in how we can obtain the required information on the numerators — and that can be very useful to ACOs when information is documented inconsistently between their practices and providers.”
The deadline hangs over many ACOs that have wanted to avoid offloading the job to a registry. As recently as 2021, only 12 ACOs opted for the voluntary eCQMs/MIPS CQMs reporting, Halpert says. “In order to report on all patients, ACOs with disparate data sources need to be able to track a unique patient across the continuum of care. Unless an ACO has the ability to aggregate data or partners with a Clinical Data Registry that can do so, they will be unable to produce valid numerators and denominators.”
In the final rule, CMS has tinkered with the requirement to make it less onerous, but still, Halpert says, “those offerings do not get to the heart of the issue, which is that many ACOs are not ready for what will be a mandatory reporting requirement in 2025.”
For the time being, these ACOs will have to console themselves that the end of the CMS Web Interface method, an unpopular side effect of the switchover, has been pushed forward again to 2024, when the new electronic reporting methods are made mandatory.
All of the significant technical adjustments floated in the proposed rule were finalized, including:
Thompson says this should be a plus for many ACOs because it will “account for the effect of ACOs on overall health care trends as well as modifying individual ACO benchmarks upon renewal to adjust their new benchmark,” and thus “‘add back’ a portion of the savings that [ACOs] created will help keep more ACOs in the game.”
The American Medical Group Association (AMGA), however, and other commenters to the proposed rule expressed concern that the new method might not work as expected. AMGA recommended that CMS “calculate the updated benchmark with the new method and under the current national-regional blend as finalized in the Pathways to Success rule. The ACO would then select the updated benchmark of its choosing.” But that recommendation was rejected.
“Uncertainty in the program just makes it that much more difficult for providers to know what they’re signing up for when they agree to participate in this,” says Darryl Drevna, AMGA’s senior director of regulatory affairs.
CMS press release, “Medicare Shared Savings Program Saves Medicare More Than $1.6 Billion in 2021 and Continues to Deliver High-quality Care,” Aug. 30, 2022: www.cms.gov/newsroom/press-releases/medicare-sharedsavings-pro