ACOs skittish over MSSP rule delay as CMS silence creates mounting uncertainty

Doctor talking to senior patient and her husband
ACOs are waiting on a signal from CMS to kick off the application process for this year's Medicare Shared Savings Program.(Getty/olgachov)

Accountable care organizations (ACOs) are growing increasingly worried about an extended delay of the Medicare Shared Savings Program (MSSP) and a lack of communication from the Trump administration.

A proposed rule that would outline regulatory changes to the ACO program has been under review by the Office of Management and Budget (OMB) since the beginning of May. Meanwhile, ACOs still don’t have applications for the 2019 participation year and they’ve received no guidance on the application process, which typically kicks off in early spring.

“Here we stand on the 27th of July and we don’t’ have a clear statement about the program, let alone an application,” Jeff Micklos, executive director of the Health Care Transformation Task Force (HCTTF) told FierceHealthcare.

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In a letter (PDF) to Centers for Medicare & Medicaid Services Administrator Seema Verma, Micklos speculated that the delay was tied to “disagreement among policymakers” about the changes to the program and that delivery of the 2019 participation solicitation may be ensnared in the rulemaking. He urged the agency to move forward with the 2019 application period separate from the proposed rule.

“Work continues on the Medicare Shared Savings Program (Shared Savings Program), although CMS has nothing new to announce at present,” a CMS spokesperson told FierceHealthcare.

For new ACOs looking to join the program, and those up for renewal, the delay creates a difficult time crunch for an extensive application process that “typically takes months,” according to Allison Brennan, the vice president of policy at the National Association of ACOs. ACOs use that time to select which ACO track to participate in and calibrate a budget, as well as add new practices and skilled nursing facilities based on ongoing negotiations with providers.

Last month, NAACO sent a letter to CMS requesting "more transparent information as soon as possible" about the application deadlines. The letter added that the delay has "led some ACOs to believe there will not be an opportunity to apply for a 2019 program start." 

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The industry will also have to account for a 60-day comment period and time for CMS to evaluate comments before the rule is finalized.

While Brennan declined to say whether any ACOs have decided not to participate based on the delay, she said “many are worried they won’t be able to get through that whole process in time for the performance year.”

Micklos added that each ACO has its own “drop dead date” depending on the size and scope of the organization.   

“I think everyone is concerned that we’re at the end of July here and kind of nowhere for 2019,” he said.

Both Verma and Department of Health and Human Services Secretary Alex Azar have repeatedly emphasized the agency’s focus on shifting towards value-based care. The agency’s unwillingness to even outline the application process for a program that many point to as primary driver behind that shift “seems inconsistent” with those goals, Micklos says.

Short of releasing the rule, ACOs are looking for a signal of reassurance from CMS that it plans to support the program in 2019 and beyond. So far, they haven’t received any.  

“CMS’ silence is leading to the uncertainty,” Brennan said.