HHS' OIG: CMS must review how MSSP overhaul is affecting ACO care

Medicare spending costs money
The Department of Health and Human Services' Office of Inspector General found that the Centers for Medicare & Medicaid Services needs to review how changes to the Medicare Shared Savings Program are affecting accountable care organizations' ability to provide value-based care. (Getty/zimmytws)

The Trump administration needs to review how major changes to accountable care organizations (ACOs) have impacted their ability to coordinate value-based care, according to a report from the Department of Health and Human Services (HHS) watchdog.

HHS' Office of Inspector General (OIG) said in a report delivered Friday that ACOs have reported successful strategies to lower Medicare spending. But the Centers for Medicare & Medicaid Services (CMS) must do better in sharing such strategies in addition to performing a review. 

“CMS should conduct this review to determine the extent to which ACOs are participating in the program and the extent to which ACOs are reducing spending and improving quality,” the report said.

The report comes after recent news that the number of new ACOs joining the program as of July 1 dipped this year compared to prior years. CMS said last week that 518 ACOs joined the program, a decline from 561 that participated in 2018.

RELATED: ACOs should plan for a shorter path to greater risk in CMS' overhauled MSSP

The Medicare Shared Savings Program (MSSP), which administers ACOs, now requires the organizations to take on risk at an earlier rate. An ACO can get a cut of savings that it generates in Medicare spending but will have to pay back the federal government if spending goes too high.

An analysis from the National Association of ACOs found that ACOs saved Medicare $2.7 billion since the inception of the program.

The revamped MSSP requires new ACOs to take on risk after three years in the program as opposed to six years under rules from the Obama administration.

The OIG interviewed 20 high-performing ACOs of the more than 500 in the program.

OIG found several strategies in improving healthcare quality, another metric CMS evaluates in judging ACO performance.

For example, the report found:

  • Almost all ACOs use care coordinators that manage the health of beneficiaries with costly or complex care needs, which make up a large amount of health spending.
  • One ACO has care coordinators ask beneficiaries with congestive heart failure, high-risk diabetes and several other ailments to call and report their health status each day.

“If a beneficiary reports a condition that requires followup, the care coordinator directs the beneficiary to a registered nurse who can request a pharmacy consultation to identify any medication errors, or arrange for hospital, home health services, or primary care services, if appropriate,” the report said.

This process resulted in a 43% reduction in emergency department visits and a 47% reduction in hospital readmissions by the second year of the ACO program.

CMS agreed with the report’s recommendations, including those to expand efforts to share information on how ACOs are reducing spending and improving quality.

The agency also agreed with a recommendation to prioritize reports of fraud and waste from ACOs.

OIG said ACOs have a great ability to root out fraud and abuse by identifying “patterns of unusual billing by a wide range of providers. This includes providers that participate in the ACO and those that do not.”