CMS has set out a goal to have 100% of Traditional Medicare beneficiaries in value-based arrangements. By accomplishing this goal, the government will reduce the almost $1T it spends on Medicare today, while achieving better health outcomes for Americans (read my full argument here). This transition will not only effect Medicare and Medicaid, but also spillover into commercial insurance, accomplishing wholistic delivery system reform. To accomplish this ambitious goal, CMS must leverage lessons from previous demonstrations to promote a select number of longitudinal models. Using MSSP as the chassis for these primary and specialty care models (read my full argument here), CMS will create a more trusted brand for congressmen and ACOs alike, signaling long-term security to the market, spurring innovation & competition, and reforming our misaligned healthcare system.

First, CMS should add a full-risk track onto MSSP (for PY2027), using the 2026 payment rule. Then, using CMMI waivers, CMMI should add High Needs and Kidney models onto the MSSP chassis (for PY2027). High needs and Kidney can choose between all of the MSSP tracks and will be required to progress up tracks according to Pathways to Success.*

• Reforming MSSP: Move toward administratively set benchmarks; increase cap on prior savings adjustments; increase data reporting standards, and more
• Enhanced Plus (EN+): Successor to ACO REACH; higher risk / higher reward track for more experienced ACOs; set the discount at 3%; require 2 years of ACO experience before joining; carry over prior savings adjustments / prepaid shared savings from REACH
• Kidney: Successor to CKCC; nephrologists at-risk for longitudinal TCoC; ACOs can choose between just the two Enhanced tracks; lower beneficiary minimums
• High Needs: Successor to the High Needs track in ACO REACH; ACOs for high-cost-high-need patients; lower beneficiary minimums; uses Concurrent HCC model
• Geo: Successor to Geographic Direct Contracting; ACOs assigned beneficiaries based on their geographic region

Sustaining VBC Reform via MSSP

Geo Model

High Needs Model

Enhanced Plus (EN+)

Kidney Model

Reforming MSSP

After all these changes, the MSSP will be something like the Ship of Theseus. If all the parts of MSSP are gradually transformed, is it the same program? At the end of the day, all that matters is CMS’s ability to deliver savings to the trust funds, signal long-term security in VBC to investors, and create a sustainable business model for ACOs that allows them to deliver high quality care to patients in need; hence, MSSP is best ship to set sail due to its historical success and strong brand.

The Ship of MSSP

Other Policy Objectives

While not all of these policy objectives help us reach the 2030 goal, they all contribute to a more efficient CMS that promotes transparency and competition.

• Market education: Healthcare is intimidating for investors and entrepreneurs due to its complexity. The Director of CMMI should talk at Y-Combinator and other incubators, as well as share digestible reading materials, to de-mystify the models that CMMI is putting out. ****
• Allow MA beneficiaries to join ACOs: Currently, MA beneficiaries are not able to switch into ACO arrangements, but ACO beneficiaries are able to switch into MA.
• Streamlining quality measures: By aligning quality measures across difference programs and reducing the administrative burden associated with documenting them, CMS will make programs easier to compare and make VBC more attractive for clinicians.
• Aligning and improving data reporting across different programs: Currently, different ACO programs deliver varied data at varied frequencies. Ensuring that all programs align to the same schedule and data contents will increase efficiency within CMS and reduce complexity for entities participating in multiple programs. Additionally, ACOs should have access to digestible dashboards that project benchmarks, detail provider performance, and other additive data that can only be found through Virtual Research Data Center (VRDC) access.
• Ease restrictions on foreign trained doctors: States should create a fast-track licensure process for highly qualified, foreign-trained physicians who have completed residency programs comparable to US graduate medical education (GME).
• Beneficiary education: ACOs should ensure that beneficiary are aware of the models they’re participating in, how they function, and the benefits they provide. CMS should consider conducting a road show on this topic at various town halls.
• FTC Jurisdiction over nonprofits: Congress should revise the Federal Trade Commission Act to expand the FTC’s authority over nonprofit healthcare entities, ensuring the prevention of unfair, competitive practices.