End to risk for Shared Savings ACOs? Two experts weigh in

by Roy Edroso on Aug 23, 2018

The August 27 issue of Part B News covers CMS’ Aug. 5 “Pathways to Success” proposed rule that seeks to push all Medicare Shared Savings Program (MSSP) participants to two-sided risk – meaning no one could enter the program, as they can now, without risking a pay cut for underperforming.

Interestingly, two top health care analysts now working with KPMG -- former CMS senior advisor Larry Kocot and former Brookings Institute senior project manager Ross White – published a two-part consideration, “Should CMS Push ACOs Into Two-Sided Risk?” in Health Affairs in July. They concluded that, to balance the need to promote value-based care by keeping risk-averse entrants with the program’s mandate to save money, CMS might try a “formal waiver process to guide the process by which ACOs are able to remain in one-sided risk for a longer period of time” before taking on risk. After the rule came out, Part B News interviewed Kocot and White:

Do you think that, in the absence of the waiver process you proposed, there will be a large exodus from the program as some observers predict?

Our Health Affairs series was not published until after CMS drafted its plan and sent it to OMB for consideration, so it is not surprising that CMS did not consider a waiver provision for inclusion in the proposed rule. CMS did create a new path in the proposed rule to make the assumption of risk more attractive for most program participants and to prevent the kind of exodus predicted by NAACOs and other organizations.

The proposed rule incrementally increases risk for ACOs over time rather than pushing them immediately into significant downside risk. CMS projected some drop-off in participation in the proposed rule — 20 current ACOs are expected to leave the program next year, and 109 current ACOs will leave the program by 2028. While some advocates believe that CMS has underestimated the potential impact on program participation, this transition plan, along with the fact that participants will be allowed to complete their current three-year agreement period before moving to the new track system, may be enough to retain many current participants and attract new ones.  

Have you any reason to believe that CMS will respond to stakeholder pressure between now and the final rule to make the burden on risk-shy MSSP participants easier than the proposed rule suggests?

CMS leadership has been quite vocal the past few months about the need to hold program participants more accountable for reducing costs and generating net savings for the Medicare program, so it is likely that CMS will keep the pressure on ACOs to assume risk on an accelerated timeline. 

That said, the proposed rule is open to public comment and CMS could make further adjustments in the final rule to provide ACOs with more flexibility on how they move to two-sided risk. We anticipate strong reactions to the proposed rule from certain ACO advocates; however, some industry groups have already applauded the proposed rule for continuing the move to value-based care across the health care system. While the changes in the proposed rule will cause some erosion in MSSP participation, we don’t anticipate that the proposed changes will derail the program.  

Do you think these changes, if made, will reverberate in the Quality Payment Program and affect the definition or other aspects of the advanced alternative payment model (APM) program? 

Given the size of the MSSP, the proposed rule could certainly have an impact on the aggregate number of clinicians participating in QPP. On one hand, a number of ACOs could drop out of the MSSP; on the other hand, the proposed rule would increase the number of MSSP ACOs that meet the definition of an advanced APM participant. Indeed, assuming no significant changes in the final rule, MSSP participation in two-sided risk tracks will likely grow to be the largest portion of advanced APM participants in the years to come.  


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