Can Your ACO Survive A Post-COVID-19 State? Did Your Track 1 Medicare Shared Savings Program (MSSP) ACO Postpone Signing a New MSSP Contract Until 2021 with a January 2022 Start Date? If so, have you considered how the COVID-19 Public Health Emergency (PHE) will impact your future MSSP participation? Now is the time to start since you’ll be planning your ACOs move from a one-sided ACO payment model to either a single year staying as one-sided followed by a glide path to two-sided or straight into a two-sided payment model. Either way, your organization will be taking on downside risk as it applies to the cost and quality of healthcare during a time much of the world has never experienced before.
First, a short history lesson on why and how MSSP has changed since inception. After the first few years of the MSSP, it was clear that something had to change in the program. Participating ACOs had essentially sent MSSP into stagnation instead of innovation for more accountable, value-based care. When the MSSP started back in 2012, several ACOs joined under one-sided payment models without downside risk and they managed to remain without risk for far too long. Unfortunately, as we have found out time and time again, if nobody is failing under a CMS innovation model then nobody (including the patient) is winning either. Downside risk was the key to moving the gears of healthcare toward accountability in a way that effects true cost reduction while also improving care quality.
The MSSP Pathways to Success finalized in 2018[1] was released to encourage ACOs to move to performance-based risk at a pace that would truly effect change. ACOs have the option to join under two different tracks: the BASIC track or the ENHANCED track. If an ACO joins under the BASIC track, (unless they are a low-revenue ACO) they can only spend the first year of their new 5-year MSSP agreement under a one-sided payment model. After year 1, they will be forced to take on downside risk as they incrementally phase-in risk while they move up the glide path from Level B (one-sided) to Level C, D, and/or E, which are all two-sided payment models. Ultimately, each ACO under the MSSP will end in a two-sided payment model at the highest level of risk, which qualifies as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program.
What does this MSSP history lesson have to do with MSSP today and the COVID-19 public health emergency (PHE)? The answer is simple… everything! When the COVID-19 PHE hit, several ACOs postponed signing a new MSSP contract, which was a smart thing to do because nobody could have predicted all the ways that COVID-19 would impact every element of healthcare. Now, many of those ACOs (specifically Track 1 ACOs) are preparing to sign new 5-year agreements with CMS, that will include downside risk as soon as the 2022 performance year or as late as the 2023 performance year.
For Track 1 ACOs in this predicament, it seems that COVID-19 is going to provide plenty of unknowns throughout the next couple of years, which will most certainly make success under an MSSP agreement tricky to navigate to. The Interim final rule[2] has done some things to make this transition period more reasonable like not including cost data in episodes of care related to COVID-19. However, the uncertainty that should scare MSSP ACOs the most is the impact of COVID-19 on benchmark calculations and what will happen to cost containment when the world gets back to the health improvement and procedure plans it had before the pandemic struck.
ReportingMD experts can help you understand what you might expect to experience in your ACO over the next few years and how to mitigate the risk as the world slowly recovers from COVID-19. How can you position your organization to avoid the turbulence of benchmark uncertainty, rising care needs (meaning rising cost threats) from work that was originally postponed due to COVID-19, and programmatic requirements that are sure to hit hard starting in 2022?
[1] Accountable Care Organizations – Pathways to Success Final Rule, 42 CFR Part 425, Federal Register (2019).
[2] CMS-5531-IFC, Interim Final Rule Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program, 2020