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


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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
(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

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

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

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.

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