In an effort to boost participation in accountable care organizations (ACOs), Medicare has significant changes to its shared savings program on tap in the proposed 2023 physician fee schedule.
As the Texas Medical Association reviews the details of the proposed regulation, staff want to hear from you before Aug. 29 about its potential impact. TMA will submit comments to the Centers for Medicare & Medicaid Services (CMS) by its Sept. 6 deadline.
With a goal of having patients in traditional Medicare transition to value-based care relationships by 2030, CMS is attempting to address some of the barriers to Medicare Shared Savings Program (MSSP) participation that physicians have long complained about, such as unnecessary red tape and a lack of capital and experience, says Kim Harmon, TMA associate vice president of innovative practice models.
For the 2022 performance year, 54 Texas ACOs are participating in the program.
The overall number of MSSP ACO participants has declined over the past few years as federal regulations force groups to assume risk at a faster pace, Ms. Harmon says. And while more than 11 million people are currently covered under MSSP, the number of patients assigned to the program continues to fall as Medicare Advantage enrollment outpaces traditional Medicare fee-for-service.
Here is an overview of key proposed changes.
Advance payments
Recognizing that solo and small group practices often lack capital, staff, and infrastructure to successfully participate in MSSP, CMS proposed advance investment payments (AIPs) for new, low-revenue ACOs serving underrepresented populations. These changes are based on the previous ACO Investment Model (2016-18), which provided upfront quarterly payments to help kickstart ACOs in rural and underserved communities, Ms. Harmon explains.
Qualifying ACOs in any geography could receive a one-time payment of $250,000 and quarterly payments of up to $45 per Medicare patient for the first two years of the agreement period (capped at 10,000 patients). If the ACO is successful, AIPs would be deducted from the shared savings award. If practices don’t achieve shared savings, the ACO would not have to return the payment unless the group prematurely withdraws from the program.
Training wheels
Beginning with performance year 2024, CMS proposes that smaller, inexperienced ACOs be allowed to remain in no-risk contracts for their initial agreement with Medicare. New ACOs could operate under a no-risk arrangement for a maximum of seven years. Those already participating in Level A or B of the BASIC track could remain in a one-sided agreement until the end of their initial agreement.
Ms. Harmon says the goal is to give ACOs more time to transition to value-based care and boost recruitment efforts among physicians who might be averse to entering into risk-based contracts.
Benchmarking
Physicians have long complained that high-performing ACOs are penalized for their success. Over time, that success lowers regional costs and in turn ACOs’ performance benchmarks and potential for financial incentives. This is especially true for rural ACOs, those with a large local market share, and areas with high Medicare Advantage participation rates, Ms. Harmon says.
In response, CMS proposes a blended method to calculate financial benchmark updates with one-third based on the U.S. per-capita cost update (a projection of how much Medicare costs will rise), and two-thirds based on the national-regional trend. CMS is also seeking feedback on additional benchmarking modifications.
Quality reporting
Currently, to qualify for maximum shared savings, ACOs must meet a threshold of 30% to 40% of a quality performance standard. Instead, CMS proposes a sliding scale for quality performance that eliminates the “all-or-nothing” cutoff. As a result, ACOs that do not meet the quality threshold could still qualify for a portion of that savings. A similar sliding scale is proposed for shared losses if an ACO participates in the ENHANCED track.
CMS also proposes adoption of an adjustment to MSSP quality performance scores to reward those ACOs providing care to patients who are dually eligible for Medicare and Medicaid or who live in underserved communities. The adjustment would add up to 10 bonus points in the ACO’s quality performance score in the Merit-Based Incentive Payment System, or MIPS.
Administrative simplification
While ACOs must continue compliance with requirements for marketing materials, under another set of proposed changes they would no longer have to submit them to CMS for review and approval prior to distribution. CMS proposes also reducing the annual patient notification requirement to once per ACO agreement period.
For those ACOs dealing with the Skilled Nursing Facility 3-Day Rule, the waiver application and review process would also be streamlined.
Email your input on the proposed Medicare Shared Savings Program rules to Kim Harmon, associate vice president of innovative practice models, or call (800) 880-1300, ext. 1460, before Monday, Aug. 29.