How to navigate the ACO landscape in a MACRA world


With the passing of MACRA by Congress earlier this year, health facilities participating in the Medicare Shared Savings Program (MSSP) began to feel the pressure of the law’s new requirements, making it hard to plan around the ever-evolving law and its impact on their ACOs.

As they await the Centers for Medicare & Medicaid Services' impending final rule on implementation of the Medicare Access and CHIP Reauthorization Act, which is expected to solidify some key tenets to the new law, there are health systems and physician practices that are finding it hard to follow a constantly changing list of guidelines, said Anas Daghestani, M.D., CEO of Austin Regional Clinic, at a panel on accountable care organizations at the CAPG Colloquium.

Austin Regional Clinic is enrolled in track one of MSSP, and Daghestani said that MACRA has led to area hospitals seeking to partner on accountable care. He said that hospital-based ACOs may struggle more, so practices or physician groups must find the right teammate.

“In our situation, we lose a little bit of control of our destiny,” Daghestani said.

Joining Daghestani at the panel was Michael Davidson, M.D., chief medical officer of Memorial Hermann Health System in Houston, which has been an example of successful shared savings under MSSP. The system is also enrolled in track one, and Memorial Hermann has been the top-performing ACO in the country for the past three years, Davidson said.

Davidson said there is talk at Memorial Hermann to move to MSSP track two or three in order to potentially capture some of the additional alternative payment model bonuses offered under MACRA, but the plans aren’t concrete. The system’s ACO success has been led by its physicians, he said, and some of what it has earned back in shared savings from MSSP is given back as bonuses to physicians.

The system divides Houston into six regions and goes to affiliated docs in each area once a quarter to discuss ways they can improve both in the ACO and beyond. These meetings are mandatory for the physicians to be eligible for the bonuses, Davidson said, so it encourages participation and engagement in the ACO process.

Choosing the best pathway for a health system, hospital or practice under MACRA can be a tough decision, as both the merit-based incentive payment system (MIPS) and advanced alternative payment models (APM) have strong pros and cons, according to another panel at the colloquium on navigating the decision.

Panelists at that discussion said it’s key that a healthcare organization have a strong idea of what its staff can do and where they’re headed. Analyze the age of physicians, how much work needs to be done to bolster health IT offerings and the culture at the facility, and then use that data to determine if the risks of the more-selective APM path is worth it.

Kurt Ransohoff, M.D., CEO and chief medical officer of Sansum Clinic in Santa Barbara, California, said leaders must understand their facility’s baseline of cost and quality before choosing either MACRA path. CMS is expected to release the final rule on how it will implement MACRA sometime this fall.