Amidst the aggressive assault on the Affordable Care Act (ACA) via an unrelenting but unsuccessful ‘repeal and replace‘ agenda, much conversation and debate in the health reform theater since Donald Trump was elected the 45th President of the United States has witnessed considerable speculation about the probable directional vector(s) of reform. The initial source of these speculative insights have been from available ‘tea leaves‘ interpretation associated with key Trump administration appointments to craft and seed a ‘TrumpCare‘ alternative.
Trump’s first appointment to serve as Secretary Health and Human Services (HHS) was Tom Price, MD, a conservative Republican Congressman and orthopedic surgeon from Georgia. Tom Price’s credentials as a warrior against legacy Medicare and Medicaid regulations and incentives is well known, as is his advocacy for a ‘putting patients first‘ narrative.
Trump also tagged Seema Verma, MPH as Administrator of CMS who’s credentials included advocacy for and implementation of Healthy Indiana, a waiver enabled block grant to the State of Indiana, intended to introduce both flexibility and opportunities for ‘innovation‘ in their Medicaid program. While a sexy and somewhat logical idea, ie, delegate block (capped) funding to the state and let it innovate on the delivery and financing side, the results of block grants nationally including Indiana’s have been admittedly mixed.
With Price’s controversial tenure and the successor appointment of Secretary Alex Azar to lead HHS, Seema Verma remains at the helm of the Centers for Medicare and Medicaid Services and is advocating for and introduced a number of reforms to both CMS and the Center for Medicare and Medicaid Innovation (CMMI) operations.
Amidst the leadership deck shuffling and shifting sands of policy initiatives offered via the a series of related Notice of Proposed Rule Making (NPRM) processes, many in the ACO space have been heads down but mindful of how amended Federal policy would affect the operations and viability of ACOs active in the Medicare Shared Savings Program (MSSP) and sequelae, ie, Next Generation ACO models and now the offered NPRM ‘CMS Proposes “Pathways to Success,” an Overhaul of Medicare’s ACO Program‘.
EDITOR’s NOTE: For additional reflection see summary via Evolent Health: ‘CMS’ New MSSP Proposal: The Five “So What’s” Every ACO Exec Should Know.’
Meanwhile, ACOs are reporting results and the community is weighing in on the efficacy of the ACO model with respect to its intended deliverables, see: Farzad Mostashari, MD, CEO of Aledade recent unbundling of results on twitter, here and a recent New England Journal of Medicine piece ‘Medicare Spending after 3 Years of the Medicare Shared Savings Program‘.
Perhaps the most comprehensive take on the state of the industry is to be found in a recent study commissioned by the National Association of ACOs. The introduction to its Executive Summary is pasted below:
The stated goal of the Medicare Shared Savings Program (MSSP) is to lower the rate of growth in healthcare spending while improving patient access to quality care. (12) MSSP Accountable Care Organization (ACO) progress toward this goal of achieving savings or reducing expenditure growth has proven controversial, in part because there are a variety of ways to measure savings that may generate different results. In this report, we describe the Dobson | DaVanzo team approach13 to measuring MSSP savings and contrast this with reported findings from CMS. We also compare our results to other published work.
Dobson | DaVanzo & Associates was commissioned by the National Association of Accountable Care Organizations (NAACOS) to conduct an independent evaluation of MSSP ACO cost savings.
The CMS method of measuring ACO performance is based on an administrative formula that creates spending targets constructed with ACOs’ historical expenditures that are used to determine whether they will receive bonus payments. It is problematic when this financial target setting approach is used as if it were a program evaluation. Indeed, when independently evaluating both the Pioneer ACO and Next Generation ACO programs, CMS contractors used a difference-in-differences regression approach to estimate savings rather than the CMS benchmarking methodology used to set financial targets and calculate bonuses or penalties. (14,15). The CMS benchmarking methodology addresses the question “How has ACO spending changed compared to prior years’ spending?” While this may be an appropriate way to set performance benchmarks, it produces a biased estimate of program savings when compared to what may have occurred in the Medicare Fee-for-Service market had the ACO program not been in place. Instead, evaluation of program savings should incorporate a carefully designed comparison group or counterfactual to account for prevailing trends in order to address the question: “How have ACOs changed expenditures compared to other providers not participating in the ACO program?”
Read the complete report from National Association of ACOs, here.
Given the release of the NPRM and the October 16th deadline for comments with an expected ‘go live’ date in early 2019, the Florida Association of ACOs (FlaACOs) upcoming annual meeting in Orlando is a timely event to compare notes and process the impact of CMS’ proposed changes with your peers.
For those of you in the Southeast with an interest in ACOs or valued based healthcare models and their performance in the greater Florida market, take note the Florida Association of ACOs (FlaACOs) convenes in Orlando, October 18th and 19th for their fourth annual meeting.
For the 5th year in a row, Health Innovation Media, publisher of ACO Watch, including Fred Goldstein, President, Accountable Health, LLC and me will be onsite interviewing keynote faculty and select participants at the FlaACOs conference.
Wednesday, September 12th at 3PM Eastern, 12 Noon Pacific, we chat with FlaACOs CEO and founder Nicole Bradberry on PopHealth Week.