path” from upside-only models to those that
include risk. During the duration of a contract
period, an ACO would advance incrementally
and automatically into a higher level of risk.
The glide path includes five levels, which CMS
has named A, B, C, D, and E. Levels A and B are
upside only, and Levels C through E include an
increasing amount of risk that eventually, at
Level E, qualifies the ACO as an Advanced APM
under the QPP.
Where a particular ACO enters the glide path
depends on previous participation in the MSSP,
specifically its Medicare fee-for-service revenue
and its experience with performance-based risk.
In general, however, current Track 1 ACOs would
enter the glide path at Level B and then advance to risk as a
Level C. Because the program is not starting until July 1, 2019,
such an ACO would have six months at Level B (July through
December 2019), plus one full year in the 2020 performance
year as an upside-only model, and then shift into risk at
Level C in January 2021. Discounting the six months in 2019,
ACOs that have previously participated in the MSSP will be
restricted to a single year in a one-sided model before progressing into a risk-based track.
Concurrent to this accelerated shift to risk, CMS also reduced
the level of shared savings for those in Level A or B—the
upside-only models—to 40%. CMS had proposed a rate of
25%, but revised it based on overwhelming objection from
AMGA and others in the stakeholder community. However, the
40% shared savings rate is below the 50% that was previously
available to upside-only ACOs. At the same time, CMS finalized a shared savings rate of 50% for Levels C, D, and E of the
glide path. Effectively, what was the shared savings rate for
upside-only models now will be the rate for two-sided models
in the Basic glide path. While CMS has acknowledged this
may reduce participation in the MSSP, AMGA believes this is
a missed opportunity for CMS to encourage participation in
a value-based model.
Shared savings or losses in the MSSP are based on how
an ACO performs against a financial benchmark. In this final
rule, CMS is expanding an earlier policy to factor regional
expenditures in an ACO’s initial agreement period. This is a
switch from factoring regional expenditures into the benchmark in an ACO’s second or subsequent agreement period.
CMS also finalized a revised methodology for incorporating
regional fee-for-service expenditures in establishing an ACO’s
benchmark. Under the final rule, CMS will reduce the weight
used in calculating the regional adjustment from 70% to
50%. In addition, CMS will cap the regional adjustment at 5%
of national Medicare fee-for-service per capita
expenditures. AMGA is concerned that using a
regional factor in an effort to set a more accurate benchmark for an ACO does not correct the
underlying issue of using historical spending to
reset or rebase an ACO’s benchmark.
Other aspects of the final rule are welcome addi-
tions to the MSSP. For example, CMS finalized a
policy to risk adjust those Medicare beneficia-
ries who are “continuously enrolled” in the MSSP.
AMGA has long supported applying Hierarchical
Condition Category (HCC) prospective risk scores
to those who are continuously enrolled in an
ACO and not just those beneficiaries who are new to the ACO
program, which was the previous policy.
In addition, several new policies will be included in
the MSSP as required by the AMGA-endorsed Creating
High-Quality Results and Outcomes Necessary to Improve
Chronic (CHRONIC) Care Act of 2017. For example, the MSSP
now will include a beneficiary incentive program that will
allow, with CMS approval, an ACO in a two-sided model to
provide an incentive payment of up to $20 for each qualifying
primary care service that a beneficiary receives from ACO
providers. While currently limited to two-sided models, AMGA
has encouraged CMS to consider expanding this incentive
program to all levels in the MSSP, including one-sided models.
The final rule also expands the use of telehealth services
by waiving the otherwise applicable geographic restrictions
on telehealth services provided to prospectively assigned
beneficiaries. The final rule allows the Enhanced track and
two-sided models in the Basic track to apply for a waiver of
the Skilled Nursing Facility 3-Day Rule.
Finding the Right Mix
This final rule and public comments from senior HHS and CMS
officials demonstrate a willingness to use the rulemaking
progress aggressively to shift providers to risk-based models. AMGA strongly supports transitioning Medicare toward
value-based payments, but also recognizes and understands
that providers need the right mix of incentives and time to
learn how to design care delivery models that not only provide
the most appropriate care but also achieve savings.
Darryl M. Drevna, M. A., is senior director, regulatory affairs at
1. D.M. Drevna and S. Skirmont. 2018. Moving the Mountain. Group
Practice Journal, 67( 9): 6-8.
AMGA is a strong
supporter of the
MSSP, since the