Successful components of CMMI programs should be folded into MSSP because of its historical success. This grouping will ensure lasting reform, consolidate resources within CMS, reduce the deficit, and increase participation in VBC. First, a higher risk track should be added to MSSP. Then, longitudinal specialty care models should be layered on top of the MSSP chassis, like PC Flex, in such a way that ACOs concurrently participate in MSSP and the specialty model. These changes will ensure permanent delivery system reform while dedicating a smaller, more talented team to the model.
Since the inception of ACO programs in 2012, MSSP is most broadly accepted as successful in reducing costs as compared to other models. While it is difficult to run a randomized controlled trial due to a lack of counterfactual evidence, research from MedPAC and other independent sources have shown that MSSP has led to a reduction in Medicare trust fund outlays, fostering bi-partisan support for the program.¹ ACO REACH, on the other hand, has literature saying that’s it lost money for the government in 2022. MSSP is a better vessel for innovation than REACH because of this bi-partisan support, it’s benchmarking mechanisms that REACH would have to adopt, and the simplicity with which ACOs can transitions tracks. On the participant side, MSSP is the most widely adopted program, especially among health systems, which have historically been the most resistant to change. CMMI should leverage this success by adding to MSSP, thereby protecting VBC programs from congressional scrutiny and allowing for the following benefits.
The historical success of MSSP would not only codify key aspects of VBC as new regulations via the rule making process (as opposed to passing laws through congress), but also…
CMMI and CMS should work hand-in-hand to streamline benchmarking calculations, data reporting, alignment algorithms, and other processes to ensure that a small group of talented individuals are building the most efficient program possible.
MSSP’s benchmarking mechanisms have been refined for over a decade and provide a more stable platform for participants to transition into value. For example, prior savings adjustments increase ACOs’ benchmarks based on the savings generated in the prior three years, mitigating the ‘ratchet effect’.² Likewise, the regional FFS adjustment typically increases the benchmark for high performing ACOs, creating more opportunity for savings. In this adjustment, if ACOs have done a better job at controlling costs than the region, the regional costs will be weighted more heavily in the benchmark and increase it. Additionally, the new capitation mechanisms in the MSSP provide ACOs with much-needed cash flow through a straightforward payment method. In MSSP, ACOs do not have to negotiate downstream FFS reduction with preferred providers but are simply paid a lump-sum based on their expected shared savings. Not only do these benchmarking mechanism provide a sense of stability for ACOs, but also the program’s bi-partisan support indicates that it will be in operation for decades to come. These factor will lead to increased participation in the program.
As touched on earlier, MSSP has led to a reduction in Medicare trust fund outlays over its 12 years of operation. In having more participants in the program, ACOs will generate incremental savings to Medicare.
A higher risk track with a 3-6% discount, in addition to MSSP’s shared savings tracks, will increase participation in VBC due to its higher upside potential and the simplified process for transitioning. Currently, ACOs in MSSP who want to participate in full-risk must apply to a completely different program. In having a full-risk track within MSSP, ACOs would be able to seamlessly switch so that more organizations (especially hospitals) can move up the ‘glide path’.
Specialty models for longitudinal care have proven successful in transitioning clinicians to value, especially as compared to bundled payment models. In folding these longitudinal specialty models into MSSP, a specialty-focused ACO would concurrently participate in the MSSP and their specialty program of choice. Similar to PC FLEX, the specialty program’s participation agreement would include modifications specific to that specialty (i.e., specialist-based attributed, lower beneficiary minimum, transplant bonuses, etc.).³
Assessing the most promising specialties for inclusion, KCC puts nephrologists at-risk for patients’ clinical and financial outcomes, as they are the ‘quarterback’ for the patient and CKD / ESRD is a particularly high-cost disease state. Similar to kidney, certain types of cancer and heart disease are expensive conditions where specialists, in this case Oncologists and Cardiologists, direct care for the patient. Opportunity exists to incorporate similar models into MSSP for specific conditions within each of these specialties (i.e., Heart Failure for Cardiology).
Although not a specialty model, a high needs model should be offered within the MSSP chassis, due to its success in the ACO REACH program. In this ‘concurrent participation’ model, ACOs must focus on complex, high-risk beneficiaries, meet reduced alignment minimums, and use a tailored risk adjustment model.