Paul Keckley: MSSP ACO proposed rule changes don't go far enough

The changes proposed by the Centers for Medicare & Medicaid Services (CMS) to the Medicare Shared Savings Program (MSSP) are an attempt to save accountable care organizations (ACOs) but they don't go far enough, said leading health economist Paul Keckley, Ph.D.

The proposal gives ACOs an additional three years before they face penalties for poor performance and offers a new model to entice providers to form ACOs.

Keckley, managing director of the Navigant Center for Healthcare Research and Policy Analysis, told FierceHealthcare in an exclusive interview Monday that the proposed rule released last week is CMS' attempt to simplify rules for ACOs in order for the program to survive. 

"I think the two things that are pretty clear is the CMS wants the ACOs to stay alive," he said. "The second is the changes don't address some of the things that the ACOs are currently participating would like to have seen."

Four out of five of the ACOs in the Medicare program lose money, he said, because of the cost of operations and collecting quality metrics. "So what CMS did not do is address the concerns of many of the ACOs to comply with the rules and report the quality measures. It's going to cost ACOs more than they save," he said.

The changes, Keckley said, don't go far enough for existing participants and, if implemented as proposed, will likely mean more of the Medicare ACOs will drop out of the program.

Indeed, a recent survey by the National Association of ACOs (NAACOS) conducted before the release of the proposed rule indicated that two out of three MSSP ACOs are "highly unlikely" or "somewhat unlikely" to remain in the ACO program.

The NAACOS said it is concerned about the significant investment ACOs must make to sustain operations, including administrative, data, compliance and care coordination costs. The survey revealed that ACO respondents report an annual mean of $1.5 million management costs directly attributable to ACO operations.

The CMS proposed rule changes are significant, NAACOS CEO Clif Gaus told MedPage Today, but he said they aren't enough to stop MSSP ACOs from leaving. "I think this will keep some ACOs in the program," he told the publication, "but it's certainly not going to keep them all."

Under the program, ACOs can share savings with Medicare when they deliver care more efficiently and meet or exceed performance benchmarks for quality care. MSSP currently includes 330 ACOs in 47 states and in its first year, 58 of the ACOs kept spending below their benchmarks by $705 million and earned shared savings payments of more than $315 million. Sixty ACOs also kept spending below their benchmark, but not enough to earn the shared savings.

Keckley said CMS will likely make further changes to the program in the final rule, which is due at some point next summer. The public can comment on the proposed rule until Feb. 6.

He said there is hope that the program will survive. "I don't think the rule will be the end of the ACOs. The majority will continue to operate, although some will drop out," he said. "The reason they will continue to operate is that managing risk for payers is the long game, and managing risk for Medicare may be a small part of that."

To learn more:
- read the MedPage Today article
- here are the NAACOS survey results

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