Posted in Accountable Care, ACO, Triple Aim

ACOs in the Medicare Shared Savings Program (MSSP): Is There a Fix?

by Gregg A. Masters, MPH

The Center for Healthcare Quality and Payment Reform just released ‘How to Fix the Medicare Shared Savings Program‘ with lead author and long term managed health care industry veteran Harold D. Miller, its President and CEO. 

Some six (6) years into the Affordable Care Act (ACA) provisions specific to Accountable Care Organizations (ACOs) the results remain mixed at best, and like the serial tweaks made to the Medicare Advantage Program, now covering some 30% of Medicare beneficiaries, the underlying ACO structural characteristics and enabling health policy regulations remain ‘on the come‘ for this still nascent and evolving delivery system model.

For the many critics of ACOs as a form of an ‘HMO lite‘ in the fee-for-services Medicare market, with none of the channeling characteristics commonly associated with HMOs, this comes as no surprise.

In this just released report, Harold Miller weighs in on the fix he sees essential for the program to achieve it’s cost containment and quality improvement objectives.  The executive summary is posted below and the full report is available here.

Executive summary:

Rather than generating savings as expected, the Medicare Shared Savings Program (MSSP) has created losses for the Medicare program for four years in a row.

Calculations by the Centers for Medicare and Medicaid Services (CMS) appear to show that ACOs with downside risk produce higher savings than the “upside-only” ACOs. However, Medicare actually spends more per beneficiary in the downside risk ACOs than in other ACOs, with no difference in quality. Moreover, ACOs that have moved to the downside risk tracks have saved less after doing so.

The risk adjustment and benchmarking formulas used by CMS can penalize ACOs that serve higher-need patients and patients living in rural areas. The greater savings attributed to downside risk ACOs may have more to do with differences in the types of patients they see than differences in the way they deliver care.

Concerns about the problems with the risk adjustment and benchmarking methodologies in the MSSP have made many ACOs unwilling to enter the downside risk tracks. Requiring all ACOs to move to downside risk could force successful ACOs to leave the program, thereby reducing Medicare savings and harming the quality of care for millions of beneficiaries.

There are other options for modifying the Medicare Shared Savings Program in order to increase Medicare savings, including dropping ACOs from the program if they fail to achieve savings after two consecutive years, reducing shared savings payments for ACOs that incur losses before achieving savings, reducing the shared savings rate below 50% for Track 1 ACOs, and/or enabling ACOs to take accountability for the specific types of services they can control rather than placing them at risk for
total Medicare spending.

Neither shared savings nor shared risk payment models solve the fundamental problems in the fee-for-service payment system. As a result, it is unlikely the MSSP will ever result in significant savings or improvements in quality, and it has the potential to harm patients by rewarding providers that withhold necessary services.

Instead of continuing to modify the Medicare Shared Savings Program, CMS should focus on implementing Patient-Centered Alternative Payment Models that provide the resources physicians, hospitals, and other providers need to successfully address their patients’ healthcare needs while holding the providers accountable for those aspects of spending and quality they can control.

Twitter Dialogue on ACO Results Reported

Today on twitter there was a representative exchange from both sides of the ACO narrative which I’m posting below for context:

MANas8U's avatar

True! Yet innovation is not cheap + anything even moderately at scale in Medicare/Medicaid is definitely not cheap. Questions while innovating: What did we learn? How can we inform our future efforts? @policywonk1

danmunro's avatar

I would argue that the evidence is already in b/c the trajectory we’re on is easy to see – and forecast. Just labeling newer efforts of ‘cost containment’ as ‘innovation’ is like rearranging (in this case expensive) deck chairs.

danmunro's avatar

But that may be the same hymnal in title only: HC Reformation I don’t think #FFS is “an addiction” that needs #ACO or #VBP rehab and the evidence that #FFS works reasonably well around the world is compelling. We don’t need single-payer, but we absolutely need single-pricing.

A Sampling of ACO Leadership on the Center for Healthcare Quality and Payment Reform Report and Associated Remedies

Our Nation’s move from volume to value based care will not occur in one day. Transformation of our complex, misaligned and disjointed healthcare system will take the hard/smart work, dedication, risk and financial support from key stakeholders, including the largest being CMS. Transition to risk based/value based care is not an option, it is a necessity not only to save but successfully advance the US Health Care system. It is easier to point out problems, than to roll up our collective sleeves and develop innovative and outside the box solutions.  – Alex Foxman, MD, FACP, CMO, President and Co-Founder National ACO, LLC

The state of Florida is a great example of ACOs having success.  I believe this is true because we already have a vibrant managed care market.  Medicare Advantage makes a lot of people money but has not proved it has saved any.  It has only served to risk adjust a population for higher revenues.  ACOs, as originally designed, may only be ‘transitional’ but they are an important step toward shifting from volume to value payment models. We should expect the models will continue to evolve.  This shift is a jog not a sprint. The goal and focus should be on the “shift” not which model and flavor is the stepping stone along the way. – Nicole Bradberry, CEO and Chair of Board, Florida Association of ACOs 

ACOs in Florida reduced expense by $365,809,069, earned shared savings payments of $178,447,886 with a net benefit to the Medicare trust fund of $187,361,183. MSSP is working in Florida! We’re concerned that the success of the MSSP is being evaluated based aggregate ACO performance which includes ACOs who are not putting forth adequate effort. I know of at least 7 ACOs that have 2 or less employees. That’s not enough effort to make ANY business model work! Unfortunately their results are tabulated with others and cause the program to be inaccurately evaluated. We look forward to the required transition to downside risk as it will require those without much commitment to drop out. If you drop the minimum effort ACOs, we expect the aggregate ACO results will look different. This is PY 2016 data… –  David Klebonis, Chief Operating Officer, Palm Beach Accountable Care Organization & Chief Operating Officer, South Florida Accountable Care Organization 

One definition of literal fantasy requires only that we accept a single non-reality, after which the rest of the story becomes quite plausible. If that be the case, Mr. Miller has written a Best Seller. His entire analysis assumes that the CMS “Shared Savings” formulas reflect reality, when those of us that have really crunched the numbers know this is far from the truth.

Intentionally or not, CMS has built significant savings for the Trust Fund into the benchmark methodologies for both MSSP and NextGen. These range from the actuarial fallacies inherent in continuous attribution, successful ACO market share effects on the “Benchmark”, National Efficiency ratios that divert Benchmark dollars from high attribution areas to low attribution areas, risk score caps, automatic “discounts” and much, much more.

Still, it seems that our Florida ACOs consistently overcome the increasing headwinds and succeed. Additionally, CMS recognizes the problems in their own Benchmarking models and has tweaked these year after year, including the latest Proposed Rule submitted by MSSP to OMB earlier this month. I fear Mr. Miller is whistling past the graveyard on this one.

For a glimpse into a few of the methodology problems, see ‘Regional Benchmarking or Regional Bonus? Sustainability in the Medicare Shared Savings Program‘. – Richard J. Lucibella, CEO, Accountable Care Options

 

A Continued Search for Answers and Business Models

Further context sourced from the Florida Association of ACOs annual conference last year was provided by Aledade co-founder and CEO and former National Coordinator for Health Information Technology at the Office of the National Coordinator Farzad Mostashari, MD here.

Weigh In

So what do you think? Please offer your thoughts in the comments section. This is a dialogue well worth a broader exchange as our industry evolves perhaps even ‘pivots’ from it’s near term PCMH or ACO roots to a the valued based healthcare model – one that many refer to as a ‘Rorschach test’ of sorts – where any projection of what constitutes a value based model will do.
Please feel free to post any resources that support your take and we’ll happily include via our social reach. If any of you are inspired to author a guest post with references of citations, we’re happy to include at ACO Watch.

 

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Posted in Accountable Care, ACO, Triple Aim

Leavitt Partners Weigh in on Medicare, APMs and Provider Readiness for Pivot

by Gregg A. Masters, MPH

It’s been busy since our re-launch at This Week in Accountable Care primarily due to the heavy lifting support from National ACO co-founders, Andre Berger MD, CEO, and Alex Foxman, MD, President and Chief Medical Officer, respectively.

While I moderate the series, Drs. Berger and Foxman serve as co-hosts and subject matter experts as we engage thought leaders and best-in-class ACO operators in focused conversation around local or regional market challenges including headwinds, tailwinds, lessons learned and emerging best practices.

Recently we’ve chatted with top national talent including: Don Crane, CEO, of CAPG, Hal Sadowy, the IPA Association of America, Jay Parkinson, MD, Founder and CEO of Sherpaa Health and author, consultant and futurist Ian Morrison.

Our all-star line-up continues in October with David Muhlestein, PhD, JD, Chief Research Officer, Leavitt Partners on Tuesday October 3rd, Farzad Mostashari, MD, Founder & CEO of Aledade on October 17th, and the rock-star advocate to fix the Affordable Care Act and former Acting Administrator of the Centers for Medicare and Medicaid Administration (CMS), Andy Slavitt on October 31st.

For our chat with David Muhlestein, PhD, JD, Leavitt Partners, Chief Research Officer you may want to read: Medicare Alternative Payment Models: Not Every Provider Has a Path Forward.

An informative Whitepaper that lays out the range of challenges most health systems, IDNs, physicians whether in groups or not face in the pivot to a value based (alternative payment models – APMs).

From the Whitepaper:

The Centers for Medicare and Medicaid Services (CMS) has shown significant support for the development of Alternative Payment Models (APMs).

CMS’ development and testing of 45 payment models has led to the adoption of similar models by other payers. Initial reports indicate that APMs could be key to producing the health care delivery reform necessary to decrease health care costs and increase delivery quality.

However, these models are only available to select provider types, and some providers, such as emergency physicians and audiologists, have no Medicare APMs in which they can participate. To realize the full benefits of APMs, additional collaboration between CMS leadership and providers is needed to develop new models for providers who do not currently have access to them.

Be sure to join us October 3rd at 5PM Pacific/8PM Eastern for a conversation with David Muhlestein on This Week in Accountable Care with Andre Berger, MD and Alex Foxman, MD. co-founders of National ACO.

Posted in Accountable Care, ACO, Affordable Care Act, Triple Aim

ACOs Fudging the Numbers?

by Gregg A. Masters, MPH

I came across this piece on the Healthcare Blog penned by Kip Sullivan, Esq, critiquing this article posted in Health Affairs last May ‘Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO‘. Sullivan raises valid points as the the legitimacy of claiming or inferring statistically insignificant results as a meaningful contribution of the subject ACO (a Partners Health sponsored venture) to ‘bending the cost curve’.

Sullivan un-bundles his argument effectively and raises issues for the industry writ large – including participating ACOs, their sponsors, the regulatory crew at both CMS and CMMI – and even the health policy press covering the sector.

I post the first few paragraphs of the piece below, for full reference the entire article on the Healthcare Blog is accessible via On the Ethics of Accountable Care Research‘.

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and ….

Comment

As someone who’s been in this dance since the mid 70s (PSROs, HSAs, HMOs, IPAs, PPOs, EPOs & all derivative plays) launched into Medicare risk via TEFRA (the Tax Equity and Fiscal Accountability Act) which introduced us to ‘Medicare Choice’ the for-runner of Medicare Advantage, I can say Sullivan’s critique of fully ‘burdening‘ ALL transformational efforts is rarely – if ever – factored into the volume to value pivot ‘investment calculus‘ of the effects of the intervention (in this case a Pioneer ACO) on the national spend.

It should be noted, the entire managed care industry can be assessed a gigantic collective FAIL for that matter as well. Since managed care penetrated ‘mainstream medicine‘ principally via extension of the HMO model typically on an IPA (independent practice association) chassis (vs. group or staff models) with the exception of a brief period in the 90s premiums continue their relentless upward march; while most payors continue to write commercial business only via an enterprise and industry wide cost shifting (risk transfer) charade. The tacit admission that there is no there there in the prevailing health insurance industry zeitgeist. They’ve proven they can NOT manage clinical risk, period.

So Kip, you might want to go a little lighter on those on the front lines trying to tame the ‘rapacious appetite’ of our ‘healthcare borg‘!

 

 

Posted in Accountable Care, health innovation challenges, health insurance reform, MSSP, Triple Aim

The Next Generation ACO: Accelerating the Transformation from Volume to Value

In January 2015, then Secretary of Health and Human Services (HHS), Sylvia Burwell outlined ‘Federal policy‘ and for the first time put a measurable stake in the ground to scale the pivot from fee-for-service to value based healthcare with concrete milestones and an associated timeline. The policy outlined seemingly scalable goals via linking 30% of traditional fee-for-service Medicare payments to quality or value through ‘alternative payment models‘ (APMs) including Patient Centered Medical Homes (PCMHs), ACOs or ‘bundled payment arrangements‘ (BPHCI) year end 2016, scaled up to 50% of payments year end 2018. For details see: ‘HHS Sets Specific Targets and Timelines for Alternative Payment Models and Value-Based Payment‘.

Now fast forward to 2017. First introduced in 2016 we’re approaching the start date of a ‘new and improved‘ ACO tagged the ‘next generation ACO model‘ now embracing an ‘all in population based payment‘ (AIPBP) option that ZERO’s out fee-for-service payments.

Between ACO operating results, significant provider community feedback via several Notice of Proposed Regulations‘ (NPRMs) and what some may say is simple commonsense, this latest iteration of the Next Generation ACO model is looking more and more like their predecessor risk bearing operators in the 80s and 90s.

As CMS notes:

Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program (Shared Savings Program), the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients. It will allow these provider groups to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

The Bottom Line

We (i.e., ACO industry operators, associated management companies’ including venture financiers, CMS and supplier stakeholders) are tweaking the ACO formula via a range of models that materially engage the provider AND payor communities as co-creators of a sustainable healthcare ecosystem embracing value and outcomes as the ‘dependent variable’.

With the uncertainty surrounding the future of the ACA and it’s likely ‘Trumpcare’ or ‘RyanCare’ replacement options, some argue ACOs are in an unspoken ‘safe harbor’ of sorts. Yet, much detail remains to be added before that picture is functionally revealed. Here at ACO Watch we’re proceeding on the assumption that ACOs or the accountable care industry collectively, are not likely to disappear anytime soon. So we’re posting some resources below:

For a deep dive into the AIPBP option CMS is hosting an Open Door Forum: Next Generation ACO Model – Overview of Population-Based Payments on Tuesday, April 11, 2017 from 4:00PM – 5:00 P.M. EDT.

For those pondering their 2018 ACO participation options, CMS‘s Center for Medicare and Medicaid Innovation (CMMI) issued an RFA (request for applications) and activated the application portal here.  

Finally to complete the picture CMS is hosting a series of open forums to provide an overview into the Next Generation ACO model offering information on the required letter of intent and on-boarding process in general on these dates as follows:

  • March 14 from 4 – 5 pm ET — Application Overview and Participating Provider Lists
  • March 28 from 3 – 4 pm ET — Benefit Enhancements Overview
  • April 11 from 4 – 5 pm ET — Overview of Population-Based Payments & All-Inclusive Population-Based Payments;and
  • April 15 — Deep Dive: Completing Your Next Generation ACO Model Participant List

For the complete list of available CMS ACO resources, click here.

And finally for those who desire an overview of the ACO theater, check out the dated but informative: ‘Accountable Care Organization (ACO) 101: A Brief Course by Neil Kirschner, Ph.D. Director, Regulatory and Insurer Affairs, American College of Physicians (ACP).

 

 

 

Posted in Accountable Care, ACO, Affordable Care Act, Triple Aim

FLAACOs 3rd Annual Fall Conference: A Retrospective

by Gregg A. Masters, MPH

This is the second year I’ve ventured to Orlando to cover the Florida Associations of ACOs (@FLAACOs) Annual gathering.

According to the website, the FLAACOs mission is:

…to provide members a vehicle to collaborate, ensuring that each healthcare organization grows and thrives. The Florida-based association aligns goals to shift physician incentives and improve health-care outcomes across the state.

FLAACOs provides a voice for the accountable care marketplace and its participating providers, payers, and individual physicians.

The goal of FLAACOs is to provide advocacy and support to all Florida accountable care organizations so that together they can become the health-care models of the future.

To many most of the managed care ‘smarts’ and thus ‘risk savvy sophistication’ typically resides in and ‘metastasizes‘ from California to other parts of the U.S. One example being the re-branding and re-positioning for growth ofCAPG formerly known as the California Association of Physician Groups who represents, advocates for and up-levels clinical risk management assumption core competencies for medical groups and ACOs nationwide. Yet, Florida is a Medicare Shared Savings Program (MSSP) hotbed market and judging from the results returned by Florida ACOs there’s a fair amount of savvy infrastructure in the ‘Sunshine state’ particularly as represented by the member ACOs participating in FLAACOs.

For more information on the conference you might review the agenda, faculty and sponsors.

For those who missed this informative conference, some of the highlights include:

flaacos_fields_keynoteA keynote presentation by Robert W. Fields, MD, Medical Director, Mission Health Partners ACO, titled ‘Key Drivers For Population Health: Redefining the Art of Medicine ‘. Our interview with Dr. Fields courtesy of Fred Goldstein is available here.

flaacos_lerer_keynoteFor the second year in a row René Lerer, MD,  President, GuideWell the parent company of a number of subsidiary companies’ including Florida Blue provided a comprehensive update detailing the dynamics of a changing ‘Payer Landscape’ given the instability of many if not all of the provisions of the ACA ‘at risk‘ under the impending Trump Administration. Prior equally informative interviews with Dr. Lerer are available here and here.

A timely panel presentation on ‘How Reimbursement Will Be Tied to Value (MACRA, MIPS, AAPM)‘ was facilitated by Kelly Conroy, Senior Advisor, Aledade, with panelists Dan Duncanson, CEO, Southeastern Integrated Medical, and Ethan Chernin, COO, BayCare Physician Partners.

Finally an extremely informative and insightful interview was offered by Mike Barrett, Sr. VP, Southeast Universal American/Collaborative Health Systems here.

An overview of FLAACOs the organization and its goals including a recap of the conference was offered by Nicole Bradberry, CEO via Fred Goldstein here.

The complete schedule and available presentation decks are here.

Posted in Accountable Care, population health, Triple Aim

Blab the Blockchain: Healthcare Implications?

by Gregg A. Masters, MPH

blockchain blab screen grab

Yesterday, April 27th 2016 I joined twitter colleagues and principal co-moderators and my ‘go-to Blab experts James Legan, MD (@jimmie_vanagon) and Charles “Chuck” Webster, MD (@wareflo) for a ‘Blab‘ on ‘blockchain implications in the heathcare space (both delivery and finance).

Our featured expert du jour Jeff Brandt was a no-show, so we winged it with an excellent overview and introduction by Chuck. We’re all learning in this space but one of the potential applications of the emerging technology might be in the granular if not seamless adjudication of complex bundled payments.

During the session many excellent references were included in the chat box. Several resources were mentioned including Smart Contracts, the Consensus 2016 conference, Youbase, and the article posted by Dan Munro on Health Standards, titled ‘Digital health lessons from BART‘.

I have a feeling there will be major application in the healthcare financing and delivery space as we progress into scaled assumption of risk under a value based healthcare incentive structure. Watch and see if you agree with some of the points made in the discussion!

 

Posted in Accountable Care, Affordable Care Act, Triple Aim

Hey, Remember IPAs, PPOs and TPAs?

by Gregg A. Masters, MPHAAPAN 2016 Forum

In a last man standing of sorts in what some may call the legacy and aging infrastructure of the ‘vote with your feet‘ PPO industry including it’s allies in the TPA (Third Party Administrator) space, the American Association of Payors, Administrators and Networks (AAPAN) is holding its 2016 Annual Forum in my former hometown of Dana Point, California at the Ritz Carlton, Laguna Nigel.

The mission of American Association of Payors, Administrators and Networks (AAPAN) notes it provides:

….the platform for the unification of payers, administrators and networks and the ability for a stronger collective public policy voice to enhance the position of each stakeholder as essential to the future of affordable healthcare delivery options centered on patient choice.

According to its subsidiary the American Association of Preferred Provider Organizations (AAPPO) the ‘PPO chassis’ accounts for:

An estimated 200 million Americans, or about 81 percent of all Americans with health care coverage (excluding those receiving military health care), receive their health care services through a PPO delivery system.

A history of managed care As a ‘collaborative association’ on behalf of the PPO industry initially positioned as a complementary (if not an HMO-lite) alternative to the more aggressive gatekeeper HMO option (see history of managed care era in graphic), AAPAN has a track record of success from advocacy, to thought leadership and operating best practices and solutions.

The Association aligns two potentially silo-ed (though synergistic) interests: the American Association of PPOs (AAPPO), the Third Party Administrators Association of America (TPAAA). For an issue brief on valued based healthcare and the need for network standards, see: The Need to Standardize Network Value-Based Purchasing Requirements.

So one might say, though a larger share of the employer based insurance market remains in a PPO type (vs. HMO) benefit plan design their role and industry leadership visibility may have been somewhat muted (if not, absent from the health reform narrative) since the rollout of the Affordable Care Act (ACA) and it’s emphasis on Accountable Care Organizations (ACOs) dominated the reform narrative.

AAPAN intends to raise this profile and remind many in the space that PPOs, TPAs and even IPAs (Independent Practice Associations) have a material and meaningful role to play in enabling the triple aim even if their initiatives aren’t tagged ACOs per se.

The 2016 Forum hashtag is #AAPAN16, and the digital dashboard is here. Do follow the tweetstream for thought leadership insights from key industry executives, entrepreneurs and change agents. See keynotes and sessions here, including Health Innovation Media co-host, Douglas Goldstein aka @eFuturist.

The program schedule is here.