NAACOS and the Challenge of the Current Moment in the Medicare ACO Programs
On August 4, the leaders of the National Association of ACOs released a statement reacting to the release of the proposed 2021 Medicare Physician Fee Schedule by the federal Centers for Medicare & Medicaid Services (CMS) the day before. As Healthcare Innovation Managing Editor Rajiv Leventhal and Senior Editor David Raths wrote, on Aug. 4, “The Centers for Medicare & Medicaid Services (CMS) on Aug. 3 released a rule that proposes changes to the Quality Payment Program (QPP) and Medicare Shared Savings Program (MSSP) for 2021. According to federal officials, because providers must stay focused on the COVID-19 pandemic, the number of significant proposed changes to the programs are limited. The QPP under MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) has included two payment paths that eligible Medicare-participating physicians could partake in—the Merit-based Incentive Payment System (MIPS) and the advanced alternative payment models (APM) track,” they wrote.
Leventhal and Raths noted that “Last year, CMS announced that a new MIPS Value Pathways (MVPs) framework, starting in 2021, will move MIPS from its current state—which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities—to a system in which clinicians will report much less. Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to APMs. MVPs will connect activities and measures from the four existing MIPS performance categories that are relevant to the population they are caring for a specialty or medical condition, according to CMS.”
They went on to say that, “In the new Aug. 3 fact sheet, however, federal officials said they recognize stakeholder concerns about this timeline, even more so now that clinicians are working hard to address the spread of COVID-19 within their practices and communities. As such, they are proposing to delay the MVPs framework until 2022. Instead, CMS is proposing a new APM Performance Pathway (APP) reporting option in 2021 to align with the MVP framework. As part of the APP introduction, the agency will also be sunsetting the CMS Web Interface as a collection type beginning in the 2021 performance period. The APP, like an MVP, would be composed of a fixed set of measures for each performance category. Those proposals and performance thresholds can be specifically seen on pages 15-16 of the fact sheet.”
Specifically with regard to the Medicare Shared Savings Program (MSSP), they wrote, “For performance year 2021, CMS is proposing that accountable care organizations (ACOs) participating in the Shared Savings Program would be required to report quality measure data for purposes of the MSSP via the APP, instead of the CMS Web Interface. Under this new reporting approach, ACOs would only need to report one set of quality metrics that would meet requirements under both MIPS and the MSSP. The total number of measures in the ACO quality measure set would be reduced from 23 to 6 measures, and the number on which ACOs are required to actively report would be reduced from 10 to 3. In addition, CMS said it is considering adding a “Days at Home” measure that is currently under development, to the APP core measure set in future years. The redesign also raises the quality performance standard for ACOs under the Shared Savings Program. Per the proposal, ACOs would now be required to receive a Quality performance score equivalent to or above the 40th percentile across all MIPS Quality performance category scores in order to share in savings or avoid owing maximum losses. Currently, ACOs have to completely and accurately report all measures and achieve at or above the 30th percentile on one measure in each domain to be eligible to share in savings.”
In the statement published to the NAACOS website on Aug. 4, NAACOS president and CEO Clif Gaus, Sc.D. stated that, “In the midst of a global pandemic and public health emergency, the Centers for Medicare & Medicaid Services (CMS) has unnecessarily proposed to completely change how ACOs are measured and report quality, replacing the current approach with a new framework and a higher performance standard. At a time when healthcare providers continue to battle the COVID-19 pandemic, CMS’s proposal to increase performance standards and make massive changes to assessments and measures is unfair and ill-timed.”
According to Gaus, “Specifically, CMS is replacing existing measures with new ones and getting rid of the reporting mechanism ACOs have relied on for years, forcing ACOs to evaluate and implement new reporting strategies with little notice. It is a considerable undertaking for ACOs to move to a new reporting process, especially while they are focused on battling a pandemic. Furthermore, CMS has ignored ACOs’ request to make quality measurement pay-for-reporting in 2020 because of the pandemic, which has caused significant utilization disruptions making it very hard to meet quality standards. “
Gaus continued, “Quality has always been a hallmark of Medicare ACO programs. No matter how much money ACOs save Medicare, they earn nothing in shared savings if they don’t hit certain quality standards, further incentivizing the best care. As a result, ACOs have outperformed fee-for-service Medicare on quality and help set the standard by which others should follow. These proposed changes are unnecessary and on balance punitive, especially if implemented during a pandemic. NAACOS appreciates CMS’s proposals to expand telehealth and increase payment rates for primary care services,” Gaus stated. “However, if all of these changes are finalized and take effect next year, there will be scant time for providers to prepare. This year’s proposed fee schedule was published historically late — and the final rule may also be after the statutory deadline of November 1 — giving much less time to understand, comment on, and prepare for changes if finalized.”
And, he added, “Another focus of the proposed rule is to update the Quality Payment Program for 2021, which will be the fifth year of the landmark Medicare effort to shift providers to value-based care, through participation in Advanced Alternative Payment Models (Advanced APMs), such as ACOs. Unfortunately, due to unrealistic increases in required thresholds for earning the Advanced APM bonus, known as Qualifying APM Participant (QP) thresholds, CMS estimates fewer providers will earn the bonus based on 2021 performance as compared to the last two years. Additionally, according to CMS’s proposal, the maximum bonuses for remaining in the default program, the Merit-based Incentive Payment System or MIPS, and avoiding the shift to value will be up to 50 percent greater than the incentive for participating in an Advanced APM. While CMS proposes slight QP modifications to assist certain providers in meeting the thresholds, that is not nearly enough to overcome the considerable jump in requirements, which is mandated by law. NAACOS urges Congress to pass the Value in Health Care Act (H.R. 7791), which, among other changes to support the shift to value, corrects the flawed QP thresholds. Without Congressional action, the transition to value will stall — just as the country faces an unprecedented health crisis and needs value-based care more than ever.”
A broader view of the landscape
Shortly after NAACOS had released that statement, Allison Brennan, NAACOS’s senior vice president of government affairs, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the current policy moment in healthcare. Below are excerpts from that interview.
Overall, what are NAACOS’s policy goals, when it comes to ACO development and value-based care delivery and payment, right now?
Broadly speaking, we are looking at how we can address some challenges that we see in the ACO program, which are illustrated by a reduced number of ACOs joining the program. They need to make sure it stays on the right track for the long term. The other component of our policy goals that ties to this is the need to address MACRA. MACRA was an overwhelmingly bipartisan bill, and there’s a lot of promise to the framework it sets out, but we’ve seen some implementational challenges, and I think it’s time for Congress to review the law and make changes.
The MSSP is a permanent part of Medicare. So for the program to continue to generate savings and provide high-quality care to beneficiaries, we need to make sure that this voluntary program continues to attract new entrants and retain current participants. Certain changes have chilled the program growth, and it’s time for us to modify some of those policies and address long-term growth in the program.
One of those changes was a reduction in the portion of savings an ACO gets to retain. With the Pathways regulation, we see ACOs go from 50 percent in the shared-savings-only model down to 40 percent. And keep in mind that ACOs don’t get any funding upfront from CMS for their initial startup or participation costs, so everything has to come out of shared savings, and reducing the shared savings rates proved to be unpalatable to many ACOs, in combination with all the other changes. Another issue that we’d like to address is the pace at which ACOs have to move to a risk-based model. In the Pathways rule. It’s now as early as the third year; previously, it was six years.
Has that change already had an impact on decision-making around participation?
It has. We see new ACOs coming into the program that don’t have the confidence they’ll be able to achieve enough savings quickly enough, before they assume risk. In 2019, the MSSP had a delayed start date of July 1; and only 5 percent of existing ACOs voluntarily moved into the Pathways structure. And that involved more flexibility to choose their assignment methodology; but it also included some unpalatable changes, and so only 5 percent of ACOs that had the opportunity to move early into Pathways, did that. I think that’s very telling; and we need to be mindful that this is a voluntary program; so we need to make that the balance of reward and risk is appropriately calibrated, in order to keep providers moving forward on the path to value.
Providers feel fragilized by the COVID-19 pandemic, but CMS officials are still speaking assertively about plunging into risk. How do you see that situation, with its inherent dynamic of tension?
That’s a great question. We’re seeing ACOs working with frontline clinicians, to keep patients out of in-person settings where possible, and doing things like making sure patients are getting their prescriptions, and getting enough to eat. So it’s clear that value-based care and payment will be needed more than ever, and that will be more true than ever, as we recover from the pandemic. The current CMS programs are voluntary programs, so we have to make sure the programs are appealing enough to providers for them to participate. And that means making adjustments, when we’re in a global pandemic. Patients have bene avoiding appointments, and care patterns have ben disrupted, so we need to make adjustments. And so in terms of quality, we’ve been asked for CMS to change the mode to pay-for-reporting, so that you’re required to report, but aren’t judged on specific outcomes. They have made some helpful program adjustments, such as removing COVID costs from ACO expenditures.
What have we learned from the COVID-19 pandemic that can help us on the journey into further value?
I think we’re learning a lot of lessons from COVID. One is that telehealth needs to play a greater role in an overall care coordination effort. We’re also seeing the downfalls of strictly fee-for-service-based payment. And it is important to consider how else providers can be paid, though there are challenges with jumping right into a full capitation model. So we’ll need to find a balance with what can meet the needs of providers, while also understanding that there will be variability in providers’ ability to shift into full-capitation models. So there will still be an element of fee-for-service-based payment. So the ACO model can be full-capitation or mixed, with an emphasis on total cost of care. I don’t think it will be a one-size-fits-all solution, but it shows the need for finding models that will be best for providers and for patients and for payers.
