CMS Announces Changes To The MSSP Designed To Increase MSSP Participation And Promote Equity Within The MSSP – Healthcare

The Centers for Medicare & Medicaid Services (CMS) recently
announced changes to the Medicare Shared Savings Program (MSSP)
designed to improve equity within the MSSP and increase the
percentage of Medicare beneficiaries in accountable care
arrangements. The changes are included in the Calendar Year 2023 Physician Fee Schedule final
rule (Final Rule), which is scheduled for publication on
November 18, 2022.

Background on the MSSP

The MSSP is CMS’s most popular value-based payment model and
was first implemented in 2012. Under the MSSP, providers and
suppliers form Accountable Care Organizations (ACOs) to manage the
quality, cost, and experience of care of an assigned Medicare
fee-for-service beneficiary population. The MSSP offers different
participation options that allow ACOs to assume various levels of
risk and earn shared savings. Over the past decade, the MSSP has
grown to be the largest value-based payment program in the country.
According to a CMS press release, the MSSP included over
525,000 participating clinicians in 483 ACOs providing care to more
than 11 million Medicare beneficiaries, as of January 2022.

The MSSP had steady growth in its early years, increasing
from 3.2 million beneficiaries participating in the MSSP in 2012 to
10.4 million beneficiaries in 2018. In recent years, however, the
number of beneficiaries participating in the MSSP has plateaued to
around 11 million. In addition, CMS notes that higher spending populations are
increasingly underrepresented in the MSSP and access to ACOs
appears to be inequitable based on data showing that people of
color are less likely to be assigned to a MSSP ACO than their white
counterparts.

Summary of the Changes

CMS’s changes to the MSSP are designed to reverse these
trends by making the MSSP more appealing to providers, particularly
providers that are new to the MSSP and/or that serve underserved
populations. Below is a summary of the most significant changes to
the MSSP.

• Advance Investment Payments for Certain ACOs. Based on feedback
  from health care providers and its experience with other
  alternative payment models, CMS recognizes that smaller providers
  and suppliers, particularly those that treat underserved
  populations, typically require upfront capital to make investments
  in order to succeed in accountable care. To reduce financial
  barriers encountered by small providers and suppliers, CMS will
  provide advance shared savings payments, called Advance Investment
  Payments (AIPs), to low revenue ACOs that are inexperienced with
  performance-based risk (i.e. two-sided risk), are new to the MSSP,
  and serve underserved populations. To receive AIPs, ACOs must
  submit a supplemental application and a proposed spend plan for CMS
  review. If approved to receive AIPs, the ACO will receive a
  one-time fixed payment of $250,000 and per-beneficiary quarterly
  payments for the first 2 years of an ACO’s 5-year agreement
  period. The quarterly payment amount is based on the number of
  beneficiaries assigned to the ACO who are enrolled in the Medicare
  Part D low-income subsidy, are dully eligible for Medicare and
  Medicaid, or reside in areas with high deprivation (measured by the
  area deprivation index). CMS will recoup AIPs made to an ACO from
  any shared savings the ACO earns.




• Transition to Performance-Based Risk. CMS will allow ACOs
  applying to the program that are inexperienced with
  performance-based risk to participate in a one-sided shared savings
  model for five years in order to provide these ACOs more time to
  invest in infrastructure and redesigned care processes before
  transitioning to performance-based risk. CMS believes this change
  will allow more small health care providers in rural and
  underserved settings to participate in the MSSP.




• Sliding Scale Approach for Determining Shared Savings.
  Presently, the current structure of the quality performance
  standard creates an “all-or-nothing” scoring where an ACO
  may be ineligible to share in savings if it does not achieve a
  certain quality performance standard, even if the difference is
  marginal. CMS will now offer an alternative quality performance
  standard based on a sliding scale reflecting an ACO’s quality
  performance for use in determining shared savings for an ACO.




• Health Equity Adjustment to ACO’s Quality Performance
  Score. In furtherance of its goal to increase equity within the
  MSSP, CMS established a health equity adjustment that will upwardly
  adjust quality performance scores of ACOs that serve a minimum
  number of underserved or dually eligible beneficiaries.




• Benchmarking Methodology Revised to Reduce the Effect of ACO
  Performance on Benchmarks. One longstanding challenge for ACOs is
  that an ACO’s success in one year lowers the cost benchmarks in
  subsequent years, making it harder for the ACO to earn shared
  savings in the future because it had to exceed its past
  performance. In the Final Rule, CMS finalized modifications to the
  benchmarking methodology to reduce the impact of ACOs’
  performance on their benchmarks. CMS is also revising its risk
  adjustment methodology to better account for medically complex,
  high cost populations.




• Reducing Administrative Burden for ACOs. CMS will no longer
  require ACOs to submit marketing materials for CMS review and
  approval prior to use. Starting in 2023, ACOs will only be required
  to provide a beneficiary notice prior to or at the first primary
  care service visit. Annual notices will no longer be required.
  However, ACOs will now be required to provide a follow-up
  communication within 180 days after providing the beneficiary
  notice. The follow-up beneficiary communication is intended to
  provide an opportunity for beneficiaries to ask any outstanding
  questions.

Overall, we expect these changes to be well-received by the
health care industry, particularly smaller health care entities and
health care entities looking to start participating in value-based
payment models. In particular, the option to participate in the
MSSP without downside risk over the full agreement period and the
availability of AIPs will likely encourage participation in the
MSSP.

The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.