CMS has discussed amending existing payment models to allow more physicians to qualify for bonus payments, but it is unclear whether changed programs would include MSSP ACOs.

May 26—Medicare could be heading toward the collapse of a large portion of its accountable care organization (ACO) program, according to a new industry survey.

Fifty-six percent of Medicare ACOs said in a recent survey that they likely would leave the Medicare Shared Savings Program (MSSP)—which hosts the vast majority of Medicare ACOs—if proposed rules making them ineligible for a key alternative payment model (APM) designation are finalized.

The rules implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) excluded as qualifying APMs many existing programs, including the Comprehensive Care for Joint Replacement (CJR) model, the Bundled Payments for Care Improvement (BPCI) initiative, and Track 1 Medicare Shared Savings Program (MSSP) ACOs, which comprise 95 percent of the 434 MSSP ACOs.

The rule estimated that as few as 30,000 physicians could qualify initially for APM payments, which are seen as more lucrative and requiring less-burdensome quality reporting under MACRA compared with the Merit-based Incentive Payment System (MIPS) track.

The National Association of ACOs (NAACOS) survey findings were not surprising to some.

"It reflects the frustration a lot of organizations feel right now," said Chad Mulvany, director of healthcare finance policy, strategy and development, for HFMA. "They are fundamentally redesigning their care delivery and payment processes, and CMS in the proposed rule seems to give that short shrift."

Other Responses

If most MSSP ACOs are excluded as qualifying APMs, the NAACOS survey found, 11 percent of such ACOs were unsure whether they would remain in the program and 32 percent said it was very or somewhat likely that they would stay in the program (with 2 percent of respondents ineligible to remain in Track 1).

David Muhlestein, senior director of research and development at Leavitt Partners, viewed the survey results as an outlier and noted in his organization's surveys of ACOs different leaders within the organizations give different responses.

"There’s a lot of speculation about what they could do," Muhlestein said in an interview. "When we talk to them thy say 'We could [leave] but we're committed to transforming care delivery so we want to stay in it.'"

Among the factors that may tilt Track 1 MSSP ACOs to continue without the APM bonus is that the law provides their physicians a "performance bump" under MIPS, Muhlestein noted.

Among those looking to stay in the Medicare ACO program by advancing beyond MSSP Track 1 was Advocate Health Care. Lee Sacks, MD, chief medical officer at Advocate, said his organization was considering moving from the MSSP to the Next Generation ACO model.

"We're going to devote a long discussion period to the pros and cons of doing that," Sacks said at a recent Washington, D.C., policy meeting.

The APMs that will qualify participating physicians for bonus payments and exemption from MIPS reporting are the Comprehensive Primary Care Plus (CPC+) program, Next Generation ACO, Medicare MSSP Tracks 2 and 3, Oncology Care Model with two-sided risk, and Comprehensive ESRD Care (for large dialysis organizations).

When asked how long their ACO would need to prepare to take on downside risk, 84 percent said six years or less. The largest share of ACOs, 44 percent, said they would be ready within three years, 40 percent within six years, and 5.5 percent in seven or more years. Also, 7.6 percent said they will never be ready to take on downside risk and 2.8 percent said they are already in a two-sided risk model (MSSP Track 2 or 3).

The survey garnered responses from 144 MSSP ACOs.

NAACOS has repeatedly urged CMS to include all ACOs as eligible APMs under MACRA as recognition for the significant investments ACOs have undertaken to provide high-quality care and meet the program’s requirements.

"ACOs fundamentally support moving toward value and improving the quality, cost, and experience of care—all of which are cornerstones of the ACO model," Clif Gaus, president and CEO of NAACOS, said in a written statement. "However, each of the CMS policies includes significant hits to ACOs that separately, let alone together, could mean the end of ACOs as we see them today."

Survey respondents said they spend an estimated average of $1.6 million on the MSSP.

"The challenge with that though is they don’t have to be doing that; that's optional," Muhlestein said about such MSSP spending.

"There are ACOs out there that haven’t invested anything in it, and they say 'If we happen to save money this year, great, if not, great.'"

CMS to Make Changes?

The concerns of existing ACOs led Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), to emphasize repeatedly in recent weeks that the agency is seeking feedback on the APM stipulations in the rule.

Slavitt said at a recent congressional hearing that CMS plans to examine all of its existing payment models "to see where we can make changes to them so that the participants in them can qualify."

But other comments from Slavitt downplayed the likelihood that APM models excluded under the proposed MACRA rules would be added.

"Even if a physician is in a model that doesn’t qualify because there is not as much nominal risk, there are still great opportunities, and there are still opportunities for them to grow into other models," Slavitt said at a May 11 hearing of the House Ways and Means Health Subcommittee.

The agency has received congressional pushback on the issue as well.

"A lot of my providers are in an early-stage, first-generation ACO model," said Rep. Ron Kind (D-Wis.). “What more can be done in order to provide an on-ramp for advanced APM payments for those early-stage ACOs, or are they going to have to just leapfrog and go on to gen two, gen three, gen four?”


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C. office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, May 27, 2016