NAACOS Warns Policymakers Over Slowing ACO Participation in the MSSP Program

On Jan. 21, the leaders of NAACOS, the Washington, D.C.-based National Association of ACOs, published a press release to the association’s website referencing newly published data from the Centers for Medicare & Medicaid Services (CMS) that shows a concerning drop in participation in the Medicare Shared Savings Program (MSSP) over the past year.

As the press release published Thursday noted, “The number of participants in the largest and most successful value-based payment program reached its lowest level since the Trump administration took office four years ago, according to new data released by the Centers for Medicare & Medicaid Services (CMS). To start 2021, 477 accountable care organizations (ACOs) are participating in the Medicare Shared Savings Program, down from a high of 561 in 2018 and the lowest since 480 participated in 2017, the Trump administration’s first year in office.”

What’s more, “The National Association of ACOs (NAACOS) blamed the steady drop in ACOs on several Trump-era policies, including 2018 changes CMS called “Pathways to Success,” which gave ACOs limited time before taking on financial risk and cut the share of savings most ACOs are eligible to keep. Last year, CMS removed the opportunity for new ACOs to apply to join the Shared Savings Program in 2021, citing the pandemic. Coupled with programmatic lows in ACOs entering the program in 2019 and 2020 because of “Pathways” changes, the incoming Biden administration inherits fewer ACOs than the Obama administration left at the start of 2017. Despite the downturn in participation, ACOs in the Shared Savings Program, whose participation is voluntary, collectively care for 10.7 million Medicare beneficiaries, more than one in six on Medicare and 30 percent not enrolled in Medicare Advantage.”

The press release quoted Clif Gaus, Sc.D., NAACOS’s president and CEO. Gaus stated, “Our healthcare payment and delivery system needs to desperately change, and ACOs offer the leading way to make that happen. A steady erosion of ACO participation damages our ability to get to where we need to be. Health Secretary Nominee Xavier Becerra and the incoming Biden administration need to re-examine the balance of incentives and risk to ensure ACO growth and continued savings to Medicare, which ACOs have a history of producing,” he added.

And, the press release went on to say, “NAACOS offers several suggestions to attract new ACOs while retaining existing ones, including immediately offer a new opportunity to apply to the Shared Savings Program for a July 2021 start date, increase ACO shared savings rates, fix key benchmarking and risk adjustment issues, allow more time before requiring risk, revisit recently finalized quality policies, minimize administrative burdens, provide more timely and complete data, and make Enhanced track voluntary.”

The following day, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Allison Brennan, NAACOS’s senior vice president of government affairs, regarding both NAACOS’s statement from the day before, and also the broader landscape of this moment in federal healthcare policy development. Below are excerpts from that interview.

Let’s start at the 40,000-feet-up view. How do you see the evolution of federal healthcare policy in the year ahead?

Much as in 2020, I think we’re in for a very important and very busy year. I think we’ll see attention and movement across a number of priorities; the first and foremost has to be the global pandemic that we’re still fighting. And I look forward to seeing additional action from Congress and the Administration on other healthcare priorities as well. I think we’ll see an emphasis on improving the ACA and improving healthcare and health insurance; a focus on health disparities; we’ll likely see attention on drug pricing; and Medicare changes, such as around value-based payment.

Will Democratic control of the White House and both chambers of Congress help to move legislation forward?

It will certainly make it easier to progress on certain issues; but given the slim majority in both houses of Congress, there will still be challenges.

What might be the biggest areas of consensus this year in Congress?

The need to address COVID will really dominate everything for now.

Do you have any guesses as to CMS Administrator?

I have no idea, honestly; numerous names are being floated around.

What do you think the biggest push areas will be for the Biden administration, versus the Trump administration, with regard to the development healthcare policy?

I definitely think we’re going to see a fresh look at how to bolster the ACA [Affordable Care Act] and the insurance exchanges. We’ll see corrections to certain Trump-era policies that watered down or created hurdles for the ACA, around the exchanges. And I think we’ll see an increased emphasis on addressing health disparities, as we’ve seen has become clarified in the current pandemic; and that falls in line with the Biden administration and some of the things we’ve seen highlighted.

What would you like the new CMS Administrator to know about risk issues?

The past couple of years, we’ve seen a number of challenges to the overall shift to value. And NAACOS has been concerned that the shift to risk has been equated to the shift to value. Risk can be an important part of the transition to value; but it is not the sole driver in the transition to value. We’ve seen tremendous progress among providers and ACOs who are making fundamental changes to how they deliver care, and operate across the industry with other stakeholders.

In other words, such elements as population health management, care management, and so on?

Exactly.

In other words, risk is one important element, but in NAACOS’s view, should not be the sole or dominant focus?

Exactly. And without changes, we’re seeing the momentum slow down, as evidenced in our report [see above].

Clearly, the decline from 561 participating organizations in 2018, to 477 right now, is not a good sign, correct?

Yes, that’s right; we’ve seen a growth in the overall Medicare program in terms of beneficiaries; but as we noted yesterday, the number of organizations participating in the MSSP is declining. As we look at these trends, we’re seeing the challenges play out, the challenges we’ve been pointing out for the past three years. Those center around an assumption that providers will continue on this path, regardless of how challenging CMS has made it. And as we look at the challenges that ACOs are facing, right now, the scale has tipped a little bit too much away from attracting and retaining providers, to the idea that we can just keep pushing providers.

We saw some positive policies that we supported during the last administration, in the Pathways to Success rules, for example, coming out of the Trump administration, that we supported. But on balance, we saw the program become more challenging. And on balance, it represents a lack of understanding of where providers are, versus where we want them to be. So we need to build a bridge there for providers, versus thinking that we push people across it.

What are a few things the new CMS Administrator can do to make providers feel supported in the MSSP?

We need clear, swift action to change policies for the MSSP, to ensure the program can get back on the right track. And examples of that include reversing the decision to cancel the 2021 MSSP class, by offering a July 2021 start date. Normally, the application process starts in the late spring for the following calendar year. But this year, because of the pandemic, they decided to cancel the application process for 2021 altogether. And we opposed that decision because, while some providers didn’t have the bandwidth, others were willing and able; so given that it was a voluntary program… And no new ACOs were able to join for 2021 as a result. So we’re calling on the Biden administration to offer the opportunity to join, starting July 1.

What will it take for more provider organizations to join MSSP at this fraught time?

I think a clear indication from the incoming administration that we need to double down on value, will help convince some providers who have been on the fence, to move forward into it. And we can make the program more attractive to entrants—for example, increasing the shared savings rates, which were slashed under the Trump administration; and allowing adequate time before providers had to assume risk. The shared savings rate went from 50 percent to 40 percent; and the time went from six years without risk to as little as two.

You really spoke out loudly on that last time, especially, but they didn’t really listen.

Especially if you consider that when an ACO is in their second year, they get their performance about eight months into the calendar year for the previous year. So the participating ACOs will get their 2020 performance results around August of 2021. That means that a provider that first entered in 2020, will get their results in late 2021, and at that point will have to decide whether to stay in the program in 2022. So they’ll be getting their results on just their first year, late into their second year, and that’s not enough information. So we have to be cognizant that people need to feel successful in a one-sided model, before they can take on a two-sided model. And that’s what we spoke about before, the false assumption that you can push providers into risk, when in actuality, you end up pushing them out of value and onto the sidelines of uncoordinated fee-for-service.

Do you think that Congress will take appropriate action in those areas where it will require congressional action?

I think there’s an appetite to focus on certain rules, such as in MACRA [the Medicare Access and CHIP Reauthorization Act of 2015]. And MACRA focuses on APMs [alternative payment models], and the rules under MACRA have been important. So I think as they revisit some of those rules, they may look at some of the rules that are chilling provider interest in MSSP. We’ll continue at NAACOS to work with our champions. For example, the introduction of the Value in Health Care Act last year included a number of provisions that would improve the MSSP. At the same time, we’ll be very focused on going back to CMS on areas that they have the authority to change. And we look forward to having new conversations with new leaders who we are hopeful will be more supportive of the transition to value.

One other priority for us is addressing the confusion and complexity regarding the overlap of various payment models. That’s another important area we think the new administration should focus on, especially after we’ve had almost a decade of innovation in exploring various payment models.

How do you see the role of the CMMI [the Center for Medicare & Medicaid Innovation], evolving forward?

We think CMMI plays a very important role in testing new payment models and concepts, and many ACOs have benefited either by participating in models or indirectly, by having some of the lessons learned applied to the permanent MSSP. However, now that we have so many lessons learned from so many different payment models, we need to prioritize what works and what’s proven, and the ACO model has demonstrated cost and quality improvements, so our recommendation is to prioritize ACOs over other payment models.