Announcing Next Gen ACO Results, CMS Administrator Verma Makes the Case for Moving ACOs to Two-Sided Risk | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Announcing Next Gen ACO Results, CMS Administrator Verma Makes the Case for Moving ACOs to Two-Sided Risk

August 27, 2018
by Heather Landi, Associate Editor
| Reprints
During the webinar, Verma discussed pushing ACOs to two-sided risk models and removing barriers to value-based care
Click To View Gallery

During a webinar sponsored by the Accountable Care Learning Collaborative Monday morning, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma reiterated the agency’s focus on pushing healthcare providers in accountable care organizations (ACOs) to take on two-sided risk while also addressing CMS’s commitment to try to remove barriers to value-based care.

During the 30-minute webinar sponsored by ACLC, a Salt Lake City-based accountable care collaborative, Verma discussed the sweeping changes that CMS is proposing for the Medicare Shared Savings Program (MSSP), noting that “it is time to take the next step.” On August 9, CMS proposed a rule that included major changes to the existing MSSP ACO program, with the goal to push ACO organizations into two-sided risk models by shortening the duration of one-sided risk model contracts. Referred to as “Pathways to Success,” CMS’ proposal looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track and the ENHANCED track.

Verma’s comments on Monday morning emphasized CMS’s firm stance on pushing healthcare providers to take on more risk, as well as CMS’s strategy of giving providers more flexibility—such as waivers around telehealth—as a reward to transitioning to value-based care.

To bolster CMS’s stance on moving ACOs to two-sided risk models, Verma announced, during the webinar, the results of a CMS evaluation report of the first performance year of the Centers for Medicare and Medicaid Innovation Center (CMMI) Next Generation ACO model. According to Verma, the evaluation showed “very promising results.” An at-a-glance document provided by CMS can be found here.

For the 2016 performance year, the Next Gen ACO Model generated net savings to Medicare of approximately $62 million while maintaining quality of care for beneficiaries, according to CMS. Overall, that represents a net reduction of 1.1 percent in Medicare spending within that program, Verma said. The Next Gen ACO model began in January 2016 with an initial cohort of 18 participants. It should be noted that 15 out of the 18 NGACOs had prior Medicare ACO experience

“What this really shows is that these Next Gen ACOs are taking the highest levels of risk and they’ve managed to maintain quality while still lowering cost,” Verma said during the webinar. “Much of the savings achieved by the Next Gen ACOs were largely due to reductions in hospital spending and spending in skilled nursing facilities, and that’s very consistent with what we’ve seen with how other two-sided ACOs have achieved savings. We’re excited about this; we think it’s a very strong start.”

Further, in a CMS press release, Verma stated, ““These results provide further evidence that ACOs succeed under two-sided risk. ACOs in the Next Generation Model are being held accountable with strong financial incentives and are provided with substantial flexibility and regulatory relief.  They are delivering value and providing quality care to patients and taxpayers even in their first performance year, and we believe that these results are achievable for other ACOs under similar incentives.”

According to CMS, the Next Generation ACO Model involves the highest levels of risk in any ACO initiative offered by CMS. In exchange, ACOs in the Next Generation Model have broader flexibility, including around the provision of telehealth and the ability to offer incentives to beneficiaries for taking steps to achieve and maintain good health. Nearly 1.5 million beneficiaries in fee-for-service Medicare are currently aligned to a Next Generation ACO, CMS stated.

“We’re going to continue to monitor this and we’re putting out the ‘next’ Next Gen by the end of 2020, and we’re starting to think about what that looks like,” Verma said. “I can tell you from a high level where we want to go with this which is we want to provide as much flexibility as possible to those who are taking two-sided risk, and we’re thinking about what kind of waivers these ACOs would like to see.”

More Flexibility for ACOs Taking on Downside Risk

When the “Pathways for Success” proposed rule was announced earlier this month, Administrator Verma was quite firm in terms of her insistence that it’s time to force the MSSP program forward, and she reiterated this perspective during the webinar on Monday. “We’ve been at this program for six years, and, in the MSSP program, we have 561 ACOs and, out of those, 460 ACOs, or 82 percent, are not taking on any risk for the increase in costs,” Verma said. CMS has noted that some Track 1 ACOs are generating losses (and therefore increasing Medicare spending) while having access to waivers of certain federal requirements in connection with their participation in the program. Meanwhile, the ACOs in two‑sided risk models “have shown significant savings to the Medicare program and are improving quality,” according to CMS.

“We’re trying to transition the structure to encourage providers to take on risk because we know that is going to deliver better outcomes,” she said.

Verma outlined that CMS’s strategy is to put pressure on ACOs to take on risk by focusing on accountability and competition—ACOs can only stay in an upside-only risk model for two years and, during that period, they are only sharing in 25 percent of the upside savings. At the same time, CMS is focused on improving quality and, for those providers who take on increasing levels of risk, CMS plans to reward those providers with increased flexibilities. CMS is proposing to allow physicians in ACOs that take on risk to receive payment for telehealth services provided to patients regardless of the patient’s location and to allow certain ACOs under performance-based risk to provide incentive payments to patients for taking steps to achieve good health.

When asked by the webinar host, Mark McClellan, M.D., director of the Duke-Margolis Center for Health Policy and co-chairman of the Accountable Care Learning Collaborative, about provider feedback on the proposed changes to the MSSP ACO program, Verma responded, “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. 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 noted, “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.”

As part of CMS’s recent “Pathways to Success” proposal, CMS has proposed taking many principles from the Next Generation ACO Model and adopting them more broadly for ACOs in the MSSP program.

During the webinar, Verma noted, “From a conceptual perspective, the more risk a provider is willing to take, the more flexible CMS wants to be. We think that way we can have providers focusing on outcomes, not the process. Rather than providers wasting time having to comply with all of our regulations, we want them instead to be focusing on patients and giving high quality care.”

Accelerating the Transition to Value-Based Care

During the webinar, Verma reiterated CMS’s commitment to accelerating the value-based transformation of America’s healthcare system, a top priority of Secretary of Health and Human Services Alex Azar.

“Our healthcare spending rate continues to grow faster than our overall economy, and actuaries project that by 2026, we’ll be spending one in every five dollars on healthcare. This trajectory is not sustainable. We look at the transition to value as trying to address some of those issues, and trying to slow down the rate of growth,” Verma said.

She continued, “Generally, as we think about value-based, and I think that means different things to different people, but from our perspective, it means paying for outcomes and paying for results, not just paying because people do things, but actually paying on a sense of what they achieve, what outcomes they have achieved and also holding providers accountable for providing cost-effective care. And we’re looking at value not only from the individual provider level, but also at a broad level, even looking at how we deal with state and the Medicaid programs, and how we’re looking at drug pricing; I think there are opportunities for value-based [models] across the entire system.”

As noted above, Verma has been firm in her insistence that it’s time to force the MSSP program forward, however, in her remarks this morning, she acknowledged that the vast majority of Medicare providers are still in a fee-for-service system and there will need to be “varying levels of risk” and a focus on providing flexibilities to move providers toward value-based care and payment models.

“If we look at where we are today, we’re about roughly one-third of individuals in the Medicare program are in a Medicare Advantage plan. We’ve got an even smaller proportion, around 11 percent, that are in some type of value-based agreement, but even there the level of risk that providers are taking is relatively small,” she said.

She continued, “If I look at where we want to go, moving forward, it’s encouraging participation in Medicare Advantage, and encouraging providers to be in some type of a value-based payment arrangement. That being said, we want to make sure that there are a variety of ways for providers to be in value-based agreements. We recognize that not every provider is going to want to take two-sided risk, or full risk, and there’s going to be varying levels of risk that providers are going to feel comfortable with. It might be appropriate for providers to take risk for a particular episode of care and some providers are going to do that over longitudinal care. I think we recognize that there is still going to be some type of fee-for-service system, so we’re looking at how we can take some of the existing policies that we have there, taking MIPS [the Merit-based Incentive Payment System], for example, and try to improve that program so that it better identifies those providers that are delivering high-value care.”

Verma also said CMS is working to address barriers to transitioning to value-based care. “I think interoperability is a big focus because we feel that we are able to deliver better coordinated care if we have a health system that is truly interoperable. We’ve done a lot of work around burden reduction, with our Patients over Paperwork initiative, and that also includes Meaningful Measures, which is about looking at the type of quality measures that we’re asking providers to report,” she said, noting that CMS also is evaluating Stark Law regulations.

CMS also is focused on supporting innovation, she said, noting payment reform around devices and telehealth. “We recently announced a proposal around remote communication technology, so we can start to have Medicare pay for some of those things,” she said. “Another thing we’ve done is unleashing a lot of the data that we have internally with CMS. We’re looking at not only releasing the Medicare Advantage data, but we’re thinking about releasing all of the Medicaid data that we’re collecting from 50 states because I think having more data out there will allow innovators to think about better ways of delivering cost effective, high quality care.”

Moving forward, CMS also intends to focus on supporting healthcare providers and ACOs with getting access to and sharing data. In the recent ACO proposal, CMS plans to require ACOs to move to 2015 certified electronic health records (EHRs) systems technology. “That’s essentially sharing information in an API (application programming interface) format, and we think that’s important to promote interoperability. At large, we’re looking at CMS putting a lot of its data into an API format; the Blue Button 2.0 initiative, that was all about putting data in an API format. We have almost 700 app developers that are using our data, and the idea there is to allow our patients to understand their data. We have heard the concerns from ACOs and other providers, and we’re also looking at ways to work directly with ACOs to improve their ability to access data from CMS,” Verma said.

 


The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


/article/value-based-care/announcing-next-gen-aco-results-cms-administrator-verma-makes-case-moving
/article/value-based-care/northern-virginia-rethinking-aco-strategies-pcps-and-specialists

In Northern Virginia, Rethinking ACO Strategies—For PCPs and Specialists

October 30, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
Inova Health's Dr. Tricia Nguyen shares her perspectives on what she and her colleagues are learning about some of the underlying challenges in ACO work

With the U.S. healthcare system undergoing rapid, transformative change, one of the big unanswered questions is, what will happen to hospital-physician alignment over time? Many physicians, burdened by bureaucracy and practice management challenges, are fleeing into employment by hospitals or by large hospital-affiliated or hospital-owned physician groups, while others are entering into a variety of contractual relationships designed to keep them afloat in practice. In a sense, physician alignment is a sort of “wild card” in the emerging healthcare system. How will accountable care and value-based healthcare delivery and payment work—will physicians mostly participate in those arrangements simply as hospital and health system employees, or will they chart a different course, somewhere between the extreme autonomy they’ve had under discounted fee-for-service reimbursement, and straight hospital system employment? No one really knows for sure, and it appears that things could evolve forward distinctly in the diverse metropolitan and regional healthcare markets across the U.S.

Some of those issues were discussed in one of the articles in this year’s Healthcare Informatics Top Ten Tech Trends story package, in the third issue of this year, in the article “Markets and Medicine—Where Do Physicians Land, in the Emerging World of U.S. Healthcare?” And one of the industry leaders interviewed for that article was Tricia Nguyen, M.D., a senior executive at the Falls Church, Va.-based Inova Health System, and who came to Inova last year in order to help to lead and expand a clinically integrated network and joint-venture insurance company, that Inova had created with Aetna. “My title was CEO of Commonwealth Health Innovation Network,” she explains. “But as it turns out, I found within 30 days that we didn’t have much to scale, so I’ve been focused internally, and now lead our population health efforts under the title of senior vice president for population health.”


Tricia Nguyen, M.D.

Dr. Nguyen sees a host of challenges, as well as definite opportunities, in the near future, in terms of how to get physicians and hospital-based health systems on the same page, and aligned to partner for the emerging future of healthcare.

Speaking of the northern Virginia healthcare market in which the five-hospital Inova system has a significant market share, Nguyen says, “This market is in a bubble; 70 percent of the population is insured by some carrier, employer-sponsored generally,” she says. The system serves a very affluent population, with “double-income, double-degree families”; and Inova controls 60 to 70 percent market share in its area. Given that market dominance, she says, “For the system, there’s not a real pressure to change, but we saw a real opportunity in this joint venture with Aetna. Providers are still making a lot of money on the fee-for-service payment schedule, because so many of their patients are commercially covered, so they don’t have to deal with a lot of government products. Some family practice and internist physicians have a high percentage of Medicare, but many are no more than 50 percent Medicare. Many are 70 to nearly 100 percent commercial. So as far as fee for value, they’re worried about MIPS and MACRA, and they want help with that.”

The important revelation that’s emerging for her and her colleagues, Nguyen says, is the realization that physician alignment to date has been missing a key component. “The primary care physicians have essentially been doing value-based care for several years here, but only for the CareFirst population,” she says, referencing CareFirst, a regional BlueCross BlueShield company that offers a range of health plans across Maryland, the District of Columbia, and northern Virginia. “Have they changed practice patterns? A little bit, but not much.” And, importantly, she says, she and her colleagues are realizing that “Fuller value will come when we can identify the high-value specialists, those who are high-performing, low-cost, given the way they practice, and using them. That to me is the secret, and no one has that secret mastered quite yet. And that’s because the tools don’t really exist to help. I believe that ACOs are too focused on primary care, and that primary care has to bear the burden to drive down the costs of care, when in fact it’s going to take collaboration with the specialists. While care coordination is important for holistic health, to generate real savings, you’re going to have to drive down specialty care costs as well.”

Inova encompasses five acute-care facilities, and employs about 500 providers, about 120 of them primary care, the rest are specialists. Inside the broader umbrella of value-based contracting, Inova operates Signature Partners, an accountable care organization with about 34,00 lives, and with a clinically integrated network (CIN). Signature Partners has been in place for over three years. “This year, “Nguyen says, “we decided to split up into two ACOs; one is a high-performing Inova medical group; the other is the original ACO that we kept going. The 34,000 number encompasses both.

One of the challenges, Nguyen says, is that “The specialists are not yet thinking about value. But the primary care doctors have been on a semi-value journey. CareFirst has created a PCMH [patient-centered medical home] model and payment model for primary care, to keep them independent. They’ve been very successful in their model. They give PCPs a certain base, and it’s under Medicare rates. And if they deem you to be PCMH, they give you x bump in your fee schedule. Once you’ve met that, for the level of engagement and savings you generate, you get that dollar amount based on your engagement and quality, as a form of an additional increase in your fee schedule for the next year.”

One of the challenges, Nguyen notes, is around the geography of her organization’s service area. “CareFirst is a health plan. They’re in Maryland and cross over to northern Virginia. It’s interesting the relationship that CareFirst has with Anthem. There’s a Highway 123 in northern Virginia. And CareFirst does not cross 123, and neither does Anthem. The program that they’ve had in place since 2012, has created virtual pods with primary care physicians, where they aggregate them together and call them a pod, and have engagement leaders and care managers, and they’re incentivized to work with care managers from CareFirst. So the primary care physicians have essentially been doing value-based care for several years here, but only for the CareFirst population.” Thus, the moderate but still-modest change in practice patterns that has been elicited from that set of contractual relationships.

Is this an example of the proverbial “one foot in the boat, one foot on the shore” phenomenon that so many are witnessing in U.S. healthcare right now? “Yes, absolutely,” Nguyen says. The existence of so many different payment systems “has kind of forced the market to think this way. About 120 of our employed medical group has a large book of business with CareFirst, and so they act differently with those populations now. They treat them as though it’s a fee-for-service environment, but our own primary care practices within are also different. There was a practice we acquired about a year ago that’s probably the premier primary care group within CareFirst. They’re one of the most efficient; and I can say that because their operational incentive award amounts are very high, among the highest in CareFirst.”

Speaking of that specific group, Nguyen says, “When I look at their ACO performance per beneficiary spend, their target spend is on average about $7,500 at most; many could run $11,000 per member per year. The way they practice is just very different. They try to manage everything virtually, telephonically, etc. We’ve started to try to uncover and find areas of opportunity to spread across our medical group, but also across our CIN. Our CIN doctors don’t really have an incentive to change. We’ve been able to generate change within the group, but the MSSP has not generated savings, so I think they’re becoming a bit disillusioned.”

What is the secret of their success? “It’s really in identifying the high-value specialists, those who are high-performing, low-cost, given the way they practice, and using them. That to me is the secret, and no one has that secret mastered quite yet. And that’s because the tools don’t really exist to help. I believe that ACOs are too focused on primary care, and that primary care has to bear the burden to drive down the costs of care, when in fact it’s going to take collaboration with the specialists. While care coordination is important for holistic health, to generate real savings, you’re going to have to drive down specialty care costs as well. And we have about 100 cardiologists we employ; and in a population of 100,000, how many cardiologists do you need? I probably have 20 times the cardiologists I need; I’m just guessing about the precise proportion, but we have an oversupply.”

Given the complexity of that situation, what is the solution to the path into value? “The solution,” Nguyen says, “is that they’re going to have to start tiering their network—by physician and not by group. They’re stuck in contracting by group. CMS [the federal Centers for Medicare and Medicaid Services] and the private payers will have to get to the level of contracting at the individual specialist level. This is how contracts happen today—under the tax ID number; and the performance of the individual provider in a group gets mixed in with their peers. And so it’s impossible to get down to that level.”

So what can CMIOs, chief quality officers, and other health system leaders do, to promote change in this context? “They can engage in provider profiling at the MPI level,” Nguyen says firmly. “Health system CMIOs need to start thinking about hospital-based specialist performance data, and claims data, in a broader, more strategic context. Nobody’s done that yet. Everybody’s mired in the whole concept of integrating EHR [electronic health record] and claims data. But so far, integrating EHR and claims data has led only to more robust reporting on select measures, but it’s primary care-specific. There’s no integrated provider reporting across their EHR, practice management data and claims data, to understand specialty care.”

For example, Nguyen says, “Take a cardiologist who practices in the hospitals and also bills for services. There’s a set of activities they do in the inpatient space that could be integrated. For example, if a patient is admitted for an acute MI, does the cardiologist provide that care or does the cardiologist also bring other specialists in? If they’re in for an acute MI, they could manage the person’s condition with consultation with a hospitalist internist, with follow-up by a diabetologist, for example. But unless a person is in acute renal care, then they need acute care by a nephrologist. But that data that can measure and performance by that specialist is available in the hospital data; you can also see it in the claims data as well. But if you take the case of an orthopedic surgeon that does a procedure in the hospital, one surgeon could cost more than another based on the prosthetics and implants. But that data is wrapped into the DRG that the hospital gets paid, and the hospital gets dinged, not the physician. And so it’s not in the claims data.”

In other words, she says, “We need to think about whom we’re holding accountable for the cost of care. It’s a shared responsibility. You have to manage the referral network and guide members to the high-value specialist. There are some basic things they can do with chronic conditions; but they must collaborate with their specialist peers.”

Does Dr. Nguyen have any other advice for CMIOs and CIOs? “Yes,” she says. “Don’t over-invest in EHR data for ACO quality measures at this time; focus on claims data. Everyone dismisses claims data. Inova has over-invested in EHR data that hasn’t yet generated savings. Claims data will help generate savings. Measuring quality, EHR yes, but a lot can be done through claims, if they’d just use the G-codes. And ACOs today are the price-takers from the payers and plans; they really should be the price-makers. And say, it’s going to cost $300 PMPM [per member per month] and not say, I’m going to take a percentage of premium, because percentage of premium could be a very arbitrary number.”

 

 


More From Healthcare Informatics

/news-item/value-based-care/report-complex-and-rapidly-changing-payment-models-challenge-physician

Report: Complex and Rapidly Changing Payment Models Challenge Physician Practices

October 26, 2018
by Heather Landi, Associate Editor
| Reprints

Physician payment models are becoming more complex and the pace of change is increasing, creating challenges for physician practices that might hamper their ability to improve the quality and efficiency of care despite their willingness to change. Those are among the findings of a new joint study by the RAND Corporation and the American Medical Association (AMA).

RAND researchers examined how alternative payment models (APMs)—payment models other than fee-for-service—have affected physician practices. For the report, “Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study,” researchers interviewed and surveyed physicians and other staff in 31 practices in six markets, including a variety of practice sizes, specialties, and ownership models.

The work was a follow-up to a 2014 study that also examined APMs’ effects on physician practices. Whenever possible, researchers re-interviewed the same physicians and practice leaders that participated in the previous study, according to a press release about the study.

“The complexity and pace of change in how physicians are paid for their services has required practices to spend substantial resources just to keep up with program details,” Mark W. Friedberg, M.D., the study’s lead author and a senior physician policy researcher at RAND, a nonprofit research organization, said in a statement. “While the practices in our sample generally voiced support for the goals of alternative payment models, these implementation challenges could make it difficult to achieve them.”

The study findings suggest that physician practice engagement with APMs would be enhanced by simpler APMs (to help practices focus on improving patient care); a more stable, predictable, and gradual pace of change; greater support for new capabilities and timely data; and reexamination of how practices might respond to APMs that involve downside financial risk.

Study Results

APMs are changing how physicians are compensated for the care of their patients to create stronger incentives for efficient, high-quality medicine. They often involve either bonuses for meeting quality goals or penalties for falling short.

In this latest study, researchers found that several trends have persisted since the 2014 study. Namely, practices have adopted new capabilities to respond to APMs. These included behavioral health capabilities, data analytic infrastructure, and information technology. Similar to the 2014 study results, the latest study found that practices substantially modified APM financial incentives before passing them through to frontline physicians. Individual physician incentives based on costs of care were rare, even within practices with strong cost-containment incentives from payers, according to the latest study.

“Despite engagement with new APMs, most practices reported that internal financial incentives for individual physicians had not substantially changed since 2014. Modest bonuses for quality performance remained common, and with the exception of small, independent practices (for which physician-owner incentives were inseparable from practice-level incentives), individual physician financial incentives based on costs of care were almost nonexistent,” the study stated.

As in the 2014 study, practice leaders deployed a range of nonfinancial strategies to influence physician decision-making, such as internal performance reports, that appealed to physicians’ competitiveness and self-esteem.

Researchers found that all the challenges described by respondents in 2014 persisted in the current study. In particular, issues related to data continued to constrain practices’ ability to understand and improve their performance. As in 2014, many physician practices -- especially those that are small and independent -- reported that they lacked the skills and experience with data management and analysis that are needed to perform well in alternative payment methods, according to the report. Building in methods to help these practices master the use of health data would improve the potential success of many alternative payment methods.

Operational errors in payment models also continued to be a source of frustration for physician practices, at times with financial consequences, according to the report.

“In some cases, these negative experiences reduced practices’ future willingness to participate in alternative payment models, even when offered by different payers. Because physician practices typically participated in multiple payment models from a variety of payers, challenges related to interactions between payment models also persisted,” the report stated.

Researchers also identified new findings regarding APMs. Across the markets studied, leaders perceived an acceleration in the pace of change in alternative payment models from both private insurers and government programs since 2014, at least partially driven by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program.

Sudden or unexpected discontinuations of APMs were particularly challenging for physician practices and other market participants that had made commitments or investments under the assumption that APMs would continue, according to the latest study.

APMs have become more complex, due to an expanding number of performance measures and uncertainty concerning performance thresholds for penalties and rewards, the respondents reported. Practices reported that understanding complex new payment models often entailed a significant resource investment. Some practices used their knowledge of complex APMs to receive more credit for their preexisting quality without materially changing patient care.

What’s more, physician practices have become more averse to APM downside financial risk. Risk aversion was especially prominent among practices that had previously experienced losses in APMs or that were inexperienced in managing risk. Some practices responded to APMs, the report stated. “In some cases, practices renegotiated contracts with payers to reduce their excessive downside risk or transfer some of that risk to partners such as hospitals or device manufacturers,” the researchers wrote.

“Physicians tell us that it’s more difficult than ever to understand the growing complexity of payment models and they are straining against a conflicting muddle of public and private value-based policies and rules that are continually in flux,” AMA president Dr. Barbara L. McAneny, said in a statement. “The resulting administrative burdens take physicians away from patient care. Today’s report is a call to action to align multiple payers and payment models with consistent measures aimed at improving patient care. It is clear the long-term sustainability of payment reform hinges on value-based payment models that must be operationally and financially sound, sustainable over time, aligned across payers, and must work for physician practices and patients. The AMA is committed to spearheading and engaging these efforts.”

In addition to finding ways to reduce the complexity of alternative payment methods, study findings suggest that a slower and more-predictable pace of change might benefit medical practices, payers and other stakeholders.

As in their previous study, researchers found that physicians were broadly supportive of alternative payment methods that enabled their practices to make noticeable improvements in patient care. They voiced satisfaction with clinical improvements, even when they did not result in financial bonuses.

However, when the alternative payment methods created new reporting and documentation burdens or when they created no perceptible improvements in patient care, physicians reported disengagement and skepticism, according to the report.

Allowing practicing physicians and other practice leaders to help design alternative payment methods might help improve physician engagement and improve the likelihood that such strategies will produce improvements in patient care, according to the report.

The study findings are intended to help guide system-wide efforts by the AMA, which sponsored and co-authored the study, and other health care stakeholders to improve alternative payment models and help physician practices successfully adapt to the changes.

 

Related Insights For: Value-Based Care

/news-item/value-based-care/lawmakers-urge-cms-modify-final-medicare-aco-regulation

Lawmakers Urge CMS to Modify Final Medicare ACO Regulation

October 24, 2018
by Heather Landi, Associate Editor
| Reprints
Lawmakers' concerns mirror concerns expressed by nine stakeholder groups in a similar letter sent to CMS last month

A bipartisan group of nine lawmakers today sent a letter to the Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma asking for two key changes to the agency’s recently proposed rule that would reform the Medicare Shared Savings Program (MSSP).

Specifically, the lawmakers asked that CMS reconsider proposals to cut the time new accountable care organizations (ACOs) have in shared savings-only models from six years to two and to decrease the shared savings rate from 50 percent to as low as 25 percent.

Lawmakers on the list include Reps. Diane Black (R-Tenn.), Peter Welch (D-Vt.), Suzan DelBene (D-Wash.), Gene Green (D-Texas), David Roe, M.D. (R-Tenn.), Greg Gianforte (R-Mont.), Tom Reed (R-N.Y.), Brad Wenstrup, M.D. (R-Ohio), and Roger Marshall, M.D. (R-Kans.).

In August, 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.

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.

In the letter, the nine lawmakers said they share CMS’s goal to ensure the ACOs under the voluntary MSSP continue to generate savings for the Medicare program and move healthcare providers toward risk and value-based models.

The lawmakers also noted that as the healthcare industry moves forward in implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), “it is imperative that MSSP ACO participation remain a workable option because MACRA’s fundamental structure is premised on the ability to participate under an Advanced Alternative Payment Model track, which primarily includes ACO models.”

The lawmakers also praise a number of improvements in CMS’ recent proposal to the MSSP program, including opportunities for reduced regulatory burden, increased beneficiary engagement and greater predictability and stability through longer agreement periods.

However, the lawmakers expressed concern with CMS’ proposal to shorten the glide path for new ACOs to assume financial risk from six years to t wo years, and to cut shared savings rate from 50 to 25 percent, specifically noting that the proposals will “have the unintended impact of impeding new ACO entry.”

“To ensure that ACOs have a sufficient business case to participate in this voluntary program, we urge CMS to modify these proposals in the final rule.

In the letter, the lawmakers also cited 2017 data from the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) that found that ACOs achieved high quality, and in particular, noted progress on important measures, such as reduced hospital admissions and screening beneficiaries for risk of falling and depression. “By CMS estimates, in 2017, 472 MSSP ACOs caring for 9 million beneficiaries participated in the MSSP, generating gross savings of $1.1 billion and an estimated net savings of $314 billion. This is consistent with independent research: a new actuarial study found that ACOs saved $1.8 billion from 2013 through 2015 and reduced Medicare spending by $540 million.”

Further, the lawmakers wrote, “peer-reviewed studies by Harvard University researchers have found that the MSSP saved more than $200 million in 2013 and 2014 and $144.6 million in 2015 after accounting for shared savings bonuses earned by ACOs.”

The lawmakers’ concerns mirror concerns expressed by nine stakeholder groups in a similar letter sent last month. The National Association of ACOs (NAACOS) and eight other healthcare stakeholder groups expressed concerns about CMS’ proposals to reduce the time new ACOs have in shared savings-only models from six to two years and to decrease the shared savings rate from 50 percent to 25 percent. The letter urges CMS to instead 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 to ensure a viable business model.

Those stakeholder groups wrote, “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.”

Clif Gaus, president and CEO of NAACOS, noted about the lawmakers’ letter, “These lawmakers understand that CMS’s proposed push to risk offers too little time and not enough opportunity for ACOs to recoup investments and threatens to cut off a pipeline of providers hoping to start the transition to value-based care,”. “NAACOS supports the move to risk, but the move needs to carefully balance incentives so not to endanger the bipartisan goal of lower-cost, higher-quality care, which ACOs have proven to help achieve.”

“Overcoming the fragmentation and volume orientation of the fee-for-service program can best be achieved by moving more providers toward greater accountability for the quality and total cost of care, as ACOs are designed to do,” Blair Childs, senior vice president of public affairs of Premier Inc., said in a statement. “Premier applauds congressional efforts to ensure that the Medicare Shared Savings Program supports providers that are making extensive investments in coordinated care models, and are working in good faith to move toward two-sided risk. This is an effort that takes time, and we should be looking to accelerate, not discourage, these efforts, particularly since they are solving many of healthcare’s biggest cost, quality and population health challenges.”

It remains to be seen how CMS will respond to the pushback from NAACOS and others of late, though up to this point CMS has taken a firm stance that upside risk-only ACOs have not been effective. Thus, the federal agency seems to be fine with these ACOs leaving the MSSP if they are unwilling to take on more risk.

 

See more on Value-Based Care

betebettipobetngsbahis bahis siteleringsbahis