Posted in ACO, Affordable Care Act, health reform, Triple Aim

The Medicare Shared Savings [ACO] Program Class of 2014: To Submit, or Not to Submit?

By Gregg A. Masters, MPH

Thinking about submitting for participation in the ‘statutory’ Medicare Shared Savings (MSSP) vs. Pioneer, or Advanced payment model ACO programs? While there is certain overlap and confusion, stay tuned for CMS to clarify both in nuance terms and well as key operational indicia. By and large my understanding is this is a provider call for participation in the MSSP.

Medicare Shared Savings Program  Application Process  National Provider Call Tomorrow, April 9th, 2013 CMS is hosting a national provider call to detail the process and timelines for the class of 2014 submissions. So if you are thinking about, or might be leaning in favor of or have made the determination to submit, this is an informational call you’ll want to participate in.

The registration details are here, and the deck is here. This will be followed by ‘Tips on Completing a Successful Application’ on Tuesday, April 23, 2013 from 1:30-3pm ET. See complete provider call summary details here.

Thanks to Alan Gilbert aka @TeamOfCare for posting the announcement via LinkedIn.

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5 thoughts on “The Medicare Shared Savings [ACO] Program Class of 2014: To Submit, or Not to Submit?

  1. $ & sense? A quick calculation on the upside/downside of an ACO leaves we wondering (your previous blog of probability of getting reward was v interesting). If the ave cost/beneficiary is $10,188 (CMS published) and is likely fixed for next 3 years (essentially the ave of the 3 yr weighted calculation from FFS). Assuming interventions to maintain patient health were not implemented or effective, the cost to manage that patient increases due to natural progression models over 3 years to $11,283. That means an average difference of $1095/yr/beneficiary. So the ACO would bill CMS the full $11,283 but have to pay back 40% of the risk-share downside (in 60/40 scenario) of $438/yr (40% X $1095), which would also be capped at 10% (or $1,128.30). Is this how the formula works? Is the average/beneficiary anticipated to be in the $10,188 range, or is that number too high/low?

    1. Paul, I personally do not dip into those weeds! There is too much granularity that is highly model dependent on driver cost (both unit price and aggregate utilization assumptions), but I can direct you to the Milliman ‘cheat sheet’ published last year:
      http://publications.milliman.com/publications/healthreform/pdfs/medicare-shared-savings-program.pdf

      We shall see what results are reported across the range of shared savings participants.

      Thanks for your question.
      Gregg

    2. Paul:

      CMS adjusts for the natural progression of disease and risk based on the change in the demographics that are continuously assigned to the ACO. So, if an ACO has 10,000 patients that were assigned at the beginning of the ACO’s participation in MSSP that remain assigned to the ACO during the first year, CMS looks at the actuarial age/sex factor for those beneficiaries in the performance year compared to the benchmark year and, for example, if that age/sex factor goes from 1.02 to 1.05 in the first performance year, the benchmark is adjusted upwards by 3% for comparing the actual claims cost in the first performance year.

      For beneficiaries that are newly assigned during the performance year, CMS looks at the HCC (risk) scores to adjust the benchmark to reflect any change in the overall risk of the ACO’s beneficiary population from the benchmark year to the performance year as a result of new ACO beneficiaries.

      It’s a little complex but I think CMS did a pretty good job of addressing the very important issue that you raised. Hope this helps.

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