AMGA Recommends Improvements to the Medicare Shared Savings Program Offers Proposal to Correct Flaw in Financial Benchmarking

ALEXANDRIA, Virginia, Oct. 16 -- The American Medical Group Association issued the following news:

AMGA today encouraged the Centers for Medicare & Medicaid Services (CMS) to revise its proposed Medicare Shared Saving Program (MSSP) rule to help improve the agency's flagship pay-for-performance model. CMS is proposing significant regulatory reforms to the MSSP which include reducing the number of years providers can participate in the program without bearing financial risk. AMGA urged CMS to abandon resetting or rebasing subsequent agreement period benchmarks using historical spending and to account for the operational challenges in transitioning to risk. AMGA also commented on ACO population risk adjustment, beneficiary incentives, payment waivers, and other issues.

"The MSSP is a proving ground for a large number of group practices that are learning how to succeed in risk-bearing payment models," said AMGA President and CEO Jerry Penso, M.D., M.B.A. "CMS is proposing numerous changes to encourage and help providers transition to risk, but we are concerned this rule does not fully appreciate how difficult this shift can be. Our comments today build on CMS' proposal by offering recommendations to improve the financial targets an ACO has to meet to be successful, and to improve the program's financial incentives."

Regional Factors in ACO Benchmarks

CMS is proposing to expand and modify its use of a regional spending adjustment factor from subsequent agreement periods to the initial ACO agreement period. AMGA is concerned this proposal does not address the underlying flaw in the MSSP's financial benchmarking methodology; namely that CMS uses an ACO's historical spending to reset or rebase financial benchmarks. Rather than attempting to mitigate the effects of the underlying flaw via the use of a regional adjustment factor, AMGA recommends CMS abandon the policy and instead, update an ACO's initial financial benchmark after the first agreement period using an annual adjustment factor that does not include the ACO's spending. This would solve the inherent problem with the calculation: that improving upon historical performance becomes increasingly difficult.

"CMS can simplify the MSSP by discontinuing the link between an ACO's performance target and its past spending. This has created a situation in which an ACO has ever-decreasing opportunity to succeed," Penso said.

More Time Needed to Transition to Risk

CMS is proposing a "glide path" that would transition ACOs from "upside-only" into models that impose financial risk. AMGA supports the transition to value-based care, but also recognizes the time needed for physicians and group practices to successfully assume financial risk in a performance-based payment model. Based on our members' experience with the MSSP, the data lag in these models, and the totality of the regulatory changes the agency is proposing, AMGA is recommending providers should have up to three years in "upside-only" arrangements, rather than two, as CMS proposes.

"Taking on financial risk through an ACO requires a significant investment in time and resources for provider groups," said Penso. "These regulatory changes, along with the lag in access to data on their beneficiaries, require additional time for providers to understand the program and their patients. An extra year provides an opportunity to learn what care delivery and practice patterns work best for a group practice and its patients. We're in support of the goals CMS has proposed, but are concerned that too speedy a transition may undermine participation in the MSSP."

Support for Risk Adjustment Proposal

Under current policy, CMS uses Hierarchical Condition Category (HCC) prospective risk scores to account for changes in the severity and case mix of newly assigned ACO beneficiaries. AMGA has encouraged CMS to more accurately risk-adjust those beneficiaries who are "continuously enrolled" in the MSSP. AMGA therefore, is pleased CMS is proposing a change reflective of our earlier recommendations to limit the distinction in risk scoring for newly and continuously assigned beneficiaries.

Voluntary Alignment, Beneficiary Opt-In, and Incentives

AMGA supports efforts that encourage Medicare beneficiaries to receive care from an ACO. Therefore, AMGA supports CMS' proposal to allow beneficiaries to align voluntarily with an ACO. CMS is proposing a beneficiary opt-in assignment methodology, which AMGA supports, provided it remains voluntary. CMS is also implementing the 2018 Bipartisan Budget Act's beneficiary incentive program. AMGA supports this program, but recommends CMS expand it. As proposed, only at-risk models could offer a benefit. AMGA recommends that this option be available to all ACOs and that CMS further incent beneficiaries to seek care within their "ACO network" by waiving copayments and deductibles.