In leveraging MSSP as ‘the chassis for innovation,’ there are over a decades worth of reforms and learnings to build upon. While this program has been more finely tuned more than others, it is not flawless. In future reforms, CMS should primarily focus on preventing the “ratchet effect” through an administratively set benchmark and reducing the administrative burden of quality reporting. These changes will provide CMS with a tool to control spending growth while offering ACOs a viable business model, as well as reduce the administrative costs associated with operating an ACO; therefore, making the program more attractive to participants. A more attractive, sustainable program gives CMS the ability to reduce the growth of prices within Traditional Medicare because providers are less dependent on fees for their services. Because all healthcare prices are linked to Medicare prices, overall price growth - the driver of our expensive healthcare system - will decrease.
“If a goal of the program is to control spending growth and if the MSSP gives Medicare a mechanism to set spending growth to desirable rates, the program will be a success; it would fulfill the task at hand, even if precise savings remain unknown… Short of a mandate, participation in the MSSP becomes de facto mandatory when the fee-for-service alternative becomes sufficiently less attractive.”
Both CMS and ACOs are aligned in trying to build a program with long-term stability and predictability. A significant threat to this stability is the “ratchet effect,” by which benchmarks are rebased and lowered due to savings achieved in the previous cycle. CMS has addressed this problem by adding the prior savings adjustment, which adds savings from the previous cycle into the rebased benchmark. This add-back is capped at 50% of savings generated, which cannot exceed 5% of national FFS spending.
A similar, significant threat to this program is the “regional ratchet effect” or “rural glitch.” When an ACO has substantial market penetration and generates savings, the regional average declines, which in turn negatively affects their benchmark. This problem is currently being solved by the regional FFS adjustment, by which an ACO’s benchmark is increased if they are more efficient than their region. Similar to the prior savings adjustment, it is capped at 5% of national FFS spending.
While there are a few ways to address these two problems, NAACOS recommends the following methodology: “Create a hybrid with the current regional adjustment. CMS would continue to weigh the regional adjustment at 50% for ACOs that are lower spending compared to their region. CMS would also add back 100% of ACOs’ prior savings achieved ABOVE the ACO’s regional adjustment, which we call ‘incremental savings.’
In moving toward an administratively set benchmark, CMS must base the the trend on an ACO’s region, as it is more reflective of spending growth than national trend. Removing national components of the trend (aka three-way blend) and removing ACO-assigned beneficiaries from regional comparison groups will create an administratively set benchmark that more accurately describes an ACO’s performance.
In reforming quality measures within MSSP, there are a number of more conservative approaches that put Band-Aids on the wound of larger problem. CMS must overhaul the quality measurement system within MSSP, lessening the administrative costs associated with VBC.
ACO REACH (requires 4 quality measures for Standard ACOs) and CKCC (requires 3) have experimented with more streamlined approaches. In REACH, 3 of the 4 measure are calculated using CMS administrative claims data, lessening the administrative burden for ACOs. Following REACH’s lead, CMS should require these four quality measures:
This approach lessens the time burden for ACOs and administrative costs throughout the system, while ensuring high-quality care to patients. These changes will allow ACOs to operate more efficiently and reduce downstream costs for patients.
Upping the data reporting standards: MSSP reports are not useful without a lot of manipulation and assumptions. These activities also increase administrative costs. Both MSSP and REACH supply ACOs with detailed monthly claims data via the Claim and Claim Line Feed (CCLF) reporting package. In addition, REACH provides monthly summarized data on risk scores, membership, and expenditures, whereas MSSP offers summarized data only quarterly.