Boon and burden of the MSSP final rule: What surprised this ACO expert most

CMS released its final rule for the Medicare Shared Savings Program last Thursday to give participating accountable care organizations more choice in risk and shared savings, finalize benchmarking policies and streamline data sharing, among other actions.

The MSSP final rule is intended to increase the flexibility of the program and make it more accessible to future ACOs.  

We checked in with Jeffery Spight, president of Collaborative Health Systems — a division of Universal American that oversees 25 ACOs — and board member for the National Association of Accountable Care Organizations. Here, Mr. Spight explains what the final rule means for the MSSP program and the ACO environment.

Question: Does anything surprise you about the final rule?

Jeffery Spight: The purpose of the rule was essentially already laid out. There were a lot of areas where the structure of the program had to change, and I commend CMS in recognizing those things quickly and wanting to make changes. I was surprised by the delay in getting elements implemented such as the benchmark methodology and by some of the waivers not getting approved in the final rule, especially regarding telemedicine. I was also surprised they didn't address risk adjustments and make them symmetrical. There is a downside element to the benchmarking where continuously assigned beneficiaries' risk can only go down, and not up. We've always argued it should also be able to go up and not just down.

Q: How will the final rule affect ACO participation and what parts of the rule do you project to have the most impact?

JS: They certainly had to create a longer onramp to the upside risk-only track, otherwise there were going to be significant departures from the program. We feel good about the general direction of the changes, but it will put a lot of ACOs in a tough place to figure out how to bridge transitions between now and when the recently passed SGR bill gets fully implemented in the next few years.

Q: How popular do you expect the new Track 3 to be?

JS: A lot of people find elements of Track 3 to be very appealing. It removes the uncertainty of which patients need to be cared for. Also the additional waiver for the three-day SNF rule is a benefit. We know from our experience at Universal American's Medicare Advantage plans that it is a great tool to be able to leverage for patients in the delivery system.

Q: Track 1 ACOs can now reapply under the final rule. What are your thoughts on this? Is it a step backward?

JS: For those ACOs just getting going I think it was vital. There were 220 ACOs up for renewal at the three-year agreement period being forced to two-sided risk, and they weren't ready for it. The longer onramp is critical. We have some ACOs early in the development process and extending them in Track 1 is really their only viable option. We also have some who have progressed and done well and are ready to take on the two-sided arrangement.

Q: CMS said they are working so ACOs will soon be able to "split" between risk tracks. Do you expect to see a lot of that?

JS: I think it's really complex. We've thought about our portfolio of ACOs and recognize that there are providers that are early in the development stage, and those further along that could succeed in a two sided risk arrangement. We are definitely going to look at the two-sided risk options, and we'll need to understand what the implications of the different attribution methodologies, shared savings rates and impact of the three-day skilled nursing facility waiver will have on each ACO's projected performance

Q: Anything you would like to add?

JS: Generally, we felt positive about the direction CMS is going. It certainly shows a commitment on their behalf to make the model sustainable and a successful part of the future of the Medicare program. We plan to be active participants in helping develop the benchmarking methodology and guiding ACOs on their way to the practice of 2020 as SGR and everything else kicks in.


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11 things to know about the MSSP ACO final rule
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