New rules for the Medicare Shared Savings Program ACOs are finalized

It will take some time to fully digest the 592 pages of new rules for the Medicare Shared Savings Program (MSSP) ACOs.

You can get started and read them for yourself here.

But few items pop out even in an Evelyn Wood reading of the first 30 or so pages.

  • CMS is going to allow the Track 1 MSSP ACOs to sign up for additional three years of one-sided risk (no surprise there) and will keep the shared savings rate at 50% (mild surprise there). The 50% shared savings rate is a victory for the MSSP ACOs. CMS had proposed cutting the rate to 40%.
  • As expected CMS is going to create a new Track 3 in MSSP with two-sided risk. This should please some health policy mavens who don’t think ACOs will have their intended effect (lowering costs while maintaining quality) unless the risk includes penalties for exceeding financial benchmarks, not just bonuses for beating them.  The existing Track 2 has two-sided risk but precious few organizations have signed up for it. But there are plenty of goodies designed to attract participants to the new Track 3, including a 75% shared savings rate, prospective assignment of beneficiaries (which makes costs more predictable), and a possible waiver of the three-day SNF rule.
  • CMS also says in the new rule that it will also consider future rule changes that might include waiving the government’s geographic requirement for telehealth services and (this is key) changing benchmarks to incorporate regional trends.

In the section on the program’s budget impact, the CMS says it expects the median amount of shared payments to total $1.13 billion from 2016 through 2018.  After taking into account shared losses of $30 million and investment and operating costs of $822 million, the net private benefit comes out to $278 million, by CMS’s reckoning.

ACOs are not managed care plans

in a discussion of patient engagement, the rule makes an interesting point that the MSSP is not a managed care program. The passage is a useful reminder that the MSSP ACOs are supposed to operate in the background, with and among providers, and not inhibit the choice of the beneficiaries.

Here is the “not managed care” passage from pages 31 and 32  of the new rule:

Additionally, as noted in this section and by some commenters, the Shared Savings Program is not a managed care program. Medicare FFS beneficiaries in the Shared Savings Program retain all rights and benefits under traditional Medicare. Medicare FFS beneficiaries retain the right to see any physician of their choosing, and they do not enroll in the Shared Savings Program. Unlike a managed care program, the assignment of beneficiaries to a Shared Savings Program ACO does not mean that beneficiaries must receive care only from ACO providers/suppliers, nor does it mean that beneficiaries must enroll in the ACO or the Shared Savings Program. Therefore, we develop patient materials with the assistance of the CMS-1461-F 32 ombudsman's office (for example, the Medicare and You Handbook, required ACO notifications, fact sheets) that state the rights and freedoms of beneficiaries under traditional FFS Medicare. We do not agree that it is appropriate for ACOs or CMS to require beneficiaries to receive all of their care from ACO participating professionals and suppliers. Rather, it is a program requirement that the ACO develop a process to promote care coordination across and among providers and suppliers both inside and outside the ACO.