Farzad Mostashari, M.D.: The MSSP Is Absolutely Proving Itself
Many healthcare leaders were elated when officials at the Centers for Medicare & Medicaid Services (CMS) on October 29 released the 2023 calendar-year results for the Medicare Shared Savings Program (MSSP), the program run by the Medicare program with the largest number of participating accountable care organizations (ACOs). As the press release from CMS on that date stated, “The Centers for Medicare & Medicaid Services (CMS) announced today that the Medicare Shared Savings Program (Shared Savings Program) continues to save Medicare money while supporting high-quality care. The Shared Savings Program yielded more than $2.1 billion in net savings in 2023 — the largest savings in the Shared Savings Program’s history. In addition, Shared Savings Program Accountable Care Organizations (ACOs) are providing higher-quality care and supporting policies CMS has adopted to enhance primary care, expand access to accountable care to underserved communities, and prioritize quality care for common chronic conditions.”
Further, the press release stated, “In 2023, ACOs in the Shared Savings Program earned shared savings payments (also known as performance payments) totaling $3.1 billion, the highest since the program’s inception more than 10 years ago. In addition, ACOs scored better on many quality measures than other types of physician groups and continued to demonstrate quality improvement. ACOs led by primary care clinicians had significantly higher net per capita savings than ACOs with a smaller proportion of primary care clinicians. These results continue to underscore how important primary care is to the success of the Shared Savings Program.
And the press release quoted CMS Administrator Chiquita Brooks-LaSure as stating that “Accountable Care Organizations in the Medicare Shared Savings Program continue to deliver high-quality health care for people with Medicare and meaningful savings for the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure. “CMS continues to improve the Medicare Shared Savings Program for the future so that providers in Accountable Care Organizations are able to deliver coordinated, high-quality, affordable, equitable, person-centered care to people with Medicare.”
The press release noted that, “From performance year (PY) 2022 to PY 2023, ACOs’ performance improved on quality measures they are required to report to share in savings. This includes statistically significant improvement on quality measures related to diabetes and blood pressure control, breast cancer and colorectal cancer screening, screening for future fall risk, statin therapy for prevention and treatment of cardiovascular disease, and depression screening and follow-up. Improvements in quality performance by ACOs underscore how this type of coordinated, whole-person care can improve treatment of common conditions, including behavioral health and cancer, helping to achieve CMS’ Behavioral Health Strategy goals and improve cancer screening rates and prevention, in line with the Cancer Moonshot goals.”
And, the press release noted, “Over the past decade, the Shared Savings Program has grown into one of the largest value-based payment programs in the country. As of January 2024, 480 Shared Savings Program ACOs include more than 608,000 clinicians who provide care to nearly 11 million people with Medicare. Based on the program’s record success and opportunities to continually improve value for people with Medicare and the health care system, CMS has set a goal that 100% of people with Traditional Medicare will be part of an accountable care relationship by 2030. CMS is also continuing steps to further strengthen the Shared Savings Program.”
And, per that, the press release quoted Meena Seshamani, M.D., Ph.D., CMS Deputy Administrator and Director of the Center for Medicare, as stating that “We continue to be encouraged and inspired by seven consecutive years of savings and high-quality care, with 2023 being the strongest year of performance to date. We are taking steps to continue to grow this impactful program to ensure those we serve have access to high-quality, affordable health care, no matter where they live.”
Leaders at the Bethesda, Md.-based Aledade, a physician enablement company that is heavily involved in helping physician groups to participate in the MSSP, were delighted. Aledade CEO and co-founder Farzad Mostashari, M.D., a nationally respected leader in U.S. healthcare—he was National Coordinator for Health IT between April 2011 and August 2013—posted a series of tweets on X on that date.
In his tweet thread on that date, Dr. Mostashari wrote asked, “Is Value-Based Care working? After a decade, we know this: The latest results for the largest such program just dropped. Giving primary care accountability for total cost and quality of care is good for patients, good for practices, and good for society.” Further, he wrote, “As the press release says, 480 ACOs providing care to nearly 11 million people with Medicare saved the gov't $5B dollars while improving quality of care. The gov't kept $2B. Providers earned an extra $3B. Beneficiaries saved on lower out-of-pocket spending-AND LESS SUFFERING.”
And, Mostashari continued, “Sure, there are alternatives! We can cut benefits to seniors. That would save money. We can cut pay for doctors. That would save money. We can do Denials or ‘Utilization Management.’ That would save money. Or we can incentivize more coordination and more primary care.” Later in the tweet thread, he wrote that “We built @AledadeACO 10 years ago with the belief that we could enable physician-led Accountable Care Organizations to succeed in these models. We are proud to now be the largest and most successful partner for practices who want to take the plunge. A million seniors in 2023.”
Shortly after these developments, Dr. Mostashari spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the 2023 MSSP results, and the future prospects of the program in general Below are excerpts from that interview.
Where should we start, in discussing all of this?
With the results we’ve announced. The MSSP is the largest value-based program in the country, and it is now clear, the most successful. What has made that program successful, and how can the lessons be expanded upon? And I think it’s an interesting contrast to the results that are frequently talked about when people are talking about the 50 or so experiments run out of the Innovation Center. Many of those experiments did not bear fruit; and the four or five that saved money and improved quality drove more participation in the MSSP and more success.
So there are two sides to this: the Center for Medicare, where the permanent programs including the MSSP live. And then the Innovation Center, which is charged with coming up from those new models. And the learnings from the new models have been moved over to the permanent program. So there are two sides of the house, with one charged with experimentation, and when the experiments work, they’re moved over to the permanent program. So when people question VBC under Medicare, they’re not really looking at the MSSP, which has evolved tremendously over the past decade-plus, and a lot o the challenges have been smoothed out and fixed, and that’s where we’re seeing improvement.”
For years now, some provider leaders have complained that the way that the benchmarks in the MSSP are organized, they’re forced to demonstrate continuous improvement in quality, year over year over year, and that, essentially, the way that the benchmarks are assembled creates some level of unfairness in the process for those MSSP ACOs that do particularly well. Is that a legitimate complaint?
It’s both legitimate and outdated at the same time. A lot of improvements have been made to the program, and many of those features have been softened: you don’t get a rebase line every year now, it’s every five years. And true, part of your benchmark comes from your own history, but a big part of it comes from your region’s performance. So you do get credit for your performance, and when they do the rebase line, they take three full years. So that was true in 2012, but sometimes people they don’t update their knowledge. So that perception is outdated, but there is a germ of truth to it, and MedPAC has said that we need to keep working on that ratchet. But in the MSSP, I will say that the ratchet has been adjusted.
What have been the biggest learnings among the successful MSSP ACOs, overall?
The single biggest learning has been that the most important thing we can do is to give access to primary care. It’s getting harder and harder to get an appointment with one’s primary care physician. It turns out that that’s huge: when you’re sick, being able to see the person who knows you best, is huge. And if you don’t reach out to your primary care doc, does your primary care practice reach out to you? Do they say, ‘Hey, we haven’t heard from you, and you haven’t filled your prescription, and your blood pressure was high.’ So that’s one, access. The second is care transition: when someone is discharged from the hospital, they’re in a very fragile condition, and in FFS, the primary care docs don’t even know where you’ve been. Third, good ACOs give the primary care doctors a 360-degree view of what’s going on with the patient, so at the point of care, when the patient does show up, they’ll know about the specialists you’ve seen, your lab results, what’s been going on outside of the practice, to be your quarterback. And the fourth thing is the wraparound: there is a smaller group who need kidney care management, congestive heart failure clinics, or end-of-life care management. That’s the fourth element of success.
Is there any cross-fertilization going on between MSSP participation and private ACO contracts?
Cross-pollination is absolutely happening, and I think there’s tremendous value in it. So we’ve set up the data, workflows, care management systems, and it’s working; and now adding in the commercial-payer contracts is great, because those contracts can ride on top of those tracks that have already been laid down. Nd there’s frankly a boost the commercial payers can get from that. I don’t think we are as far along on the commercial contracts; and this is where that outdated perception is in fact accurate: in far too many of the commercial contracts, there is a full annual ratchet, and that’s obviously not sustainable on the commercial side. So the employers need to what Medicare has done and make these contracts more sustainable.
As you know, the CMS actuaries this June projected that the total cost of U.S. healthcare is going to zoom from a current figure around $4.8 trillion per year, to $7.7 trillion by 2032. We have a lot of Debbie Downers in U.S. healthcare saying that the MSSP isn’t accomplishing enough in terms of the coming cost cliff. Your thoughts?
We do have to push harder. But this is literally the first time in my 30 years in healthcare, that, after so many pilots, etc., we’ve shown at Aledade that we’re getting 7 percent lower cost of care across the country, in urban and rural areas, with community health centers and private practices; this is the first time that a program has been proven to save money and improve quality, so let’s please celebrate that for a millisecond! And then how do we expand that from 11 million to 30 million. And it is meaningful, when it’s coming from reducing hospitalization, ED visits, etc., through care coordination. And I Googled what percentage of total healthcare cost in America is cancer care? And it’s 5 percent. So getting 7-percent savings is like curing cancer; it’s nothing to be sneezed at.
And what will this landscape look like a few years from now?
I think we’ll cross over the 50-percent mark—a majority of seniors will be taken care through accountable care or through Medicare Advantage. I don’t know whether these benefits will be extended among patients whose employers provide insurance. And we have to take a serious look at all the intermediaries in the self-insured employer market and ask whether they’re bringing value, or is it just the same old tired discounts off of fake list prices that they’re sold?
And it seems that the data and analytics are both getting better now, correct?
Oh, one-hundred percent. And the reason why Aledade gets the results we get consistently, year over year, is because of our technology, analytics stack, and products stack; it has four components: one is an interoperability engine. And our healthcare system is getting better at bringing the data together. Second, we make predictions, and predictive analytics and AI and machine learning are getting better. And we have a workflow engine that takes all those predictions and says, do this now; so we put it into action. And the final element is a feedback mechanism, to help support work towards goals, etc. So it’s all four of those quadrants that are getting better and better.
