Medical-led ACOs see the challenges in the new Medicare model: report


Smaller health care organizations (ACOs) run by doctors need more government support to succeed under the latest Medicare Shared Savings Program (MSSP) regulations, said a group of experts from the Duke Health Policy Center. Margolis in a new report.
In their Pathways to Success program, which went into effect last year, the Centers for Medicare and Medicaid Services (CMS) require ACOs to move forward to take downside financial risks faster than in the old MSSP model.

The problem is that most of the ACOs in the program have only taken upward risks, allowing them to share Medicare savings without having to share losses if they exceed a benchmark for the total cost of care. According to the researchers, much more infrastructure, experience and capital is required to take the downside risk, and not all ACOs are up to the task.
As of July 2019, according to the report, there were approximately 246 ACOs directed by doctors at the MSSP, which represents 45% of the participants in the program. To date, small and physician-directed ACOs have been more likely than larger and hospital-directed ACOs to achieve savings while providing high quality care.

ACOs run by doctors are more likely to take downside risks than other types of ACOs. But they have also left the MSSP at higher rates than other ACOs, partly due to concerns about increased financial risk.

It takes more time
To find out how these ACOs responded to Pathways to Success, Duke researchers interviewed five ACO leaders and two executives of "ACO facilitators." These are external companies, such as Aledade, Caravan and Evolent, that provide technical assistance and initial capital of ACO, including support for care management, access to information technology infrastructure and data analysis support.
Several of the ACO leaders mentioned the importance of the ACO Investment Model, a CMS program that provided advanced shared savings to provide capital to the new ACOs. Unfortunately, CMS has discontinued this program, the report said.

In the MSSP review, CMS recognized that medical-led ACOs would need a longer transition period to take downside risks than other ACOs due to their lack of capital and limited infrastructure.
Due to the difficulty of identifying ACOs directed by doctors, the CMS used the income statement as a proxy. It gave the inexperienced and "low income" ACOs a transition period of up to 3 years compared to up to 2 years for other ACOs. But not all ACOs run by doctors have low incomes.
Another change in the MSSP policy that could help medical-led ACOs is the new methodology for calculating the limits of shared losses. In Pathways to Success, ACOs can start on the basic route, which includes five levels, and migrate to the enhanced route.
The first two basic levels involve only one upside risk, while levels C, D and E require that ACOs assume ascending levels of bilateral risk. The improved track provides an even higher level of risk.

To protect small ACOs that could be eliminated by large losses, CMS gave them the option to base their maximum loss on the lowest percentage of the total cost of care, known as the benchmark, or a percentage of their annual income. of the MSSP.

While its advantages would generally remain the same, a low-income ACO would have a lower or similar downward exposure if it based its shared losses on those revenues instead of the benchmark, William Bleser, managing associate of the Duke Center told Medscape -Margolis. Medical news

In addition, CMS is allowing smaller ACOs to participate in two-sided risk lanes with fewer capital reserves than were previously required, according to the report. Under the above rules, CMS set this amount at one percent of the reference point of an ACO, which was a significant challenge for smaller ACOs. Pathways to Success reduced this amount by calculating the reimbursement of losses to CMS as a percentage of revenue instead of the reference.

Other necessary strategies
However, the researchers said that "these efforts to mitigate the increase in risk exposure may not offer enough security for physician-directed ACOs … to participate (in the MSSP)."

The initial capital to hire care coordinators, a slower transition to risk and the learning collaborations convened by CMS would make the program more attractive for small ACOs run by doctors, they said.

While the report did not say how long the transition period should be, Bleser said another Duke-Margolis investigation indicates that a minimum of 3 years may be necessary to stabilize participation in a bilateral risk program.

In addition, the researchers noted, a smoother transition from basic to improved tracks is required. When an ACO passes from basic level E to improved, Bleser observed, the percentage of shared savings that can double from 10% to 20% of the ACO benchmark.

But shared losses increase much faster. At basic level E, they represent 4% of the benchmark or 8% of income. On the improved track, the ACO can lose up to 15% of the reference point. Then, the disadvantage increases much more than the advantage in the discontinuous CMS scheme.

MSSP ACOs would also benefit, according to the report, if CMS provided more timely performance data and feedback reports. This has been a complaint of many ACOs and magnifies the challenge of having only 2 years to begin taking downside risks, Bleser said.

After the first year at the MSSP, he says, it may be 6 months before an ACO begins to see CMS performance data. At that time, the ACO has been in the program for 18 months, and has to decide whether to take downside risks at the end of the second year.

"That can be a little scary," he says.

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