The Centers for Medicare & Medicaid Services (CMS) today released a long-awaited proposed rule that would make major changes to the Medicare Shared Savings Program (MSSP). Under the MSSP, accountable care organizations (ACOs) that meet quality-of-care targets and reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the savings they achieve for the Medicare program.
The rule will be published in the December 8 Federal Register. Comments are due to CMS by February 6, 2015. Premier is currently analyzing the proposed regulation and will be developing a detailed summary and comments to CMS.
CMS is seeking comment on a number of adjustments to the MSSP, including:
Refining Medicare beneficiary assignment: CMS proposes to augment the current assignment methodology by allowing beneficiaries to join an ACO by attesting that a practitioner participating in the ACO is responsible for their care coordination. CMS also proposes to assign beneficiaries to an ACO in the first step of the attribution methodology if they received a plurality of the primary care services not only from primary care physicians within that ACO, as is the current rule, but also from nurse practitioners, physician assistants and clinical nurse specialists within that ACO. Finally, the proposal would remove from the second step of the assignment process certain specialty types whose services are not likely to be indicative of primary care services.
Legal waivers: CMS proposes to waive certain fee-for-service payments and regulations related to qualifying hospital stays for skilled nursing facility admission, telehealth, qualifications for home health services, and qualifications for post-acute referrals.
ACOs seeking to renew their participation in the program: CMS proposes to allow ACOs in “Track 1” that have met the quality performance standard in at least one of the first two years and have not generated losses that exceed the negative minimum savings rate (MSR) to renew their participation in the MSSP under the one-sided model for one additional agreement period, but at a lower shared savings rate. Specifically, CMS proposes to reduce the already inadequate shared savings payments for ACOs extending their contract under Track 1 from 50 percent to 40 percent in year 4, stepping payment down an additional 10 percent each year to reach 20 percent in year 6. Under current regulations, ACOs can only continue in the program if they begin to share financial losses after their initial agreement period, which is three years.
Changes to Track 2: CMS proposes to make the MSR and the minimum loss rate (MLR) for Track 2 variable, ranging from 2.0 percent to 3.9 percent, rather than the existing flat 2.0 percent.
New two-sided risk model: CMS proposes creating a “Track 3” risk model that integrates elements from the Pioneer ACO Model including higher rates of shared savings (up to 75 percent) and prospective attribution of beneficiaries (a list of assigned beneficiaries provided at the beginning of the performance year with no additional beneficiaries being added to the list during the performance year).
Data sharing and administrative burden: To address beneficiary confusion caused by the current data ‘opt-out’ option, CMS proposes to remove the requirement that ACOs notify beneficiaries directly through mailings or at the point of care of the opportunity to decline to have their data shared. Instead, CMS will allow ACO participants to provide written notification at the point of care through signs posted in their facilities that direct beneficiaries who expressly want to decline data sharing to call 1-800 Medicare, rather than passing the information through the ACO.
Alternative methodologies for establishing, updating, and resetting ACO financial benchmarks: CMS proposes alternative methodologies for establishing ACO benchmarks that determine shared savings and losses are gradually more independent of the ACO’s past performance and more dependent on the ACO’s success in being more cost efficient relative to its local market. Examples include transitioning the methodology for establishing, updating and resetting the ACO financial benchmark to a regional approach, changes to the risk adjustment normalization and coding intensity adjustments, and how comparison groups are defined.
Governing body composition: CMS proposes to remove the ability for ACOs to deviate from the requirement that ACO participants have at least 75 percent control of the governing body. CMS also proposes to explicitly prohibit an ACO provider/supplier from servings as the Medicare beneficiary on the governing body. Finally, CMS proposes to reiterate that an ACO must have a mechanism for shared governance, and clarifies that an ACO comprised of multiple ACO Participants must include representatives from more than one participant on the governing body.
Leadership and management structure: CMS proposes to provide additional flexibility around the qualifications of the ACO medical director by removing or altering the requirement that the medical director be an ACO provider/supplier. In addition, CMS proposes to remove the provision that allows ACOs to enter the program without satisfying the operations and clinical management requirements of the program. Finally, CMS proposes to require applicants to the program to submit documentation regarding the qualified healthcare professional responsible for the quality assurance and improvement program of the ACO.
Quality reporting requirements: CMS indicated in the proposed rule that changes to the MSSP quality reporting requirements were finalized in the CY 2015 Medicare physician fee schedule rule, and thus CMS does not put forth any proposals in this rule.
Blair Childs, senior vice president of Public Affairs for Premier, released a statement in response to the proposed rule.