In a recent letter to the Centers for Medicaid & Medicare Services, the National Association of ACOs (NAACOS) made several recommendations for how CMS could bring more innovation to the Medicare Shared Savings Program (MSSP). Aisha Pittman, M.P.H., NAACOS’ senior vice president of government affairs, spoke with Healthcare Innovation in detail about the policy recommendations to accelerate the adoption of value-based care.

Healthcare Innovation: One thing your letter to CMS says is that MSSP innovation has been stalled since the 2019 Pathways to Success rule, which created an on-ramp to risk. Why do you think it stalled? Did the pandemic have something to do with that or did CMS have its focus on other alternative payment models?

Pittman: From an alternative payment model perspective, MSSP is the only permanent one and sits outside of the CMS Innovation Center. That Pathways to Success rule was the last time that we saw major changes to the program. There are, of course, minor changes year over year. But in that time, the Innovation Center has tested a variety of approaches in ACO models, including Next Gen and then REACH. There are flexibilities and approaches in those models that have proven to be successful, even though those models overall did not meet the criteria for permanence and expansion. There are aspects of the models that were really successful, and those are some of the things that we think we should bring into the permanent model to spur innovation.

HCI: Let's talk about some of those innovations. One is basically capitation, or more predictable payment structures. A second is a voluntary alignment option. A third is working on improving quality reporting. Can we walk through those three and talk about what kinds of things you'd like to see happen?

Pittman: One of the challenges is that ACOs are still built on a fee-for-service structure, so you are subject to all of the requirements around billing for certain codes, and the thought is eventually we can move away from some of those fee-for-service structures. Capitation is one of the ways that you get there. 

A challenge for ACOs is if you're successful and achieve shared savings, you get that check a year and a half after the performance year. It has been proven that addressing cash flow helps people perform better. We know that giving ACOs shared savings up front allows them to invest earlier. That's one approach. Another approach is through capitation, which addresses the funds flow and allows practices to not have to manage to the CPT code book and be able to think about their investments differently and have a guaranteed, steady cash flow. I think that was one of the lessons from the pandemic — it's really important, particularly for primary care practices, to have that steady, guaranteed cash flow, and that's what capitation options allow you. 

Beyond primary care, capitation also creates a pathway for engaging specialists. If you have capitation beyond primary care, that allows you to enter into gain-sharing agreements or other downstream payment agreements with specialists serving beneficiaries of the ACO.

HCI: Your letter notes that voluntary alignment resulted in nearly 20 times greater alignment in ACO REACH. I had no idea that you'd see that kind of dramatic improvement. So is there any counter-argument for why not to do the voluntary alignment in MSSP?

Pittman: We don't think so. There are guardrails on the voluntary alignment. This is really about the provider practice that is in an ACO helping ensure that all of their beneficiaries are aligned. You do not get complete alignment because of how the plurality of services work. So if you have a younger, healthier patient who is not regularly seeking care, they might not align to your ACO. Or if you have a patient who is having an acute exacerbation of something and is primarily seeing a specialist first for something or had a surgery in that year, and is really focused on their follow-up, they’re not going to align to the ACO either. Because it is based on primary care services, these are the patients where we see churn. You would want to keep them in, so the voluntary alignment really helps close that gap. The other place that it really closes the gap is new-to-Medicare beneficiaries.

HCI: What are some ways that current quality reporting requirements are decoupled from how ACOs actually work on improving care? And what are some suggestions for how they could be improved?

Pittman: In recent years in the Shared Savings Program, CMS has moved away from the historical reporting approach, which was called the Web Interface, to requiring ACOs to move toward electronic clinical quality measures (eCQMs). We think that moving toward digital quality measures, which would be pulling in data from the EMR as well as other sources such as lab data, is the best way to go. We're not ready for that yet, with all of the interoperability challenges. We do think we should be building toward that. 

But right now, where we are with the requirement to use eCQMs, there are still interoperability challenges with EMRs. If you think about it from an ACO perspective, they are pulling in EMR data from hundreds of instances of EMRs. Even if you’re on the same brand of EMR, it could be a different instance, and there are a lot of interoperability challenges. Our members spend a lot of time and have whole dedicated teams that just focus on pulling together data for the purposes of meeting the quality reporting requirements. 

Separately, they have clinical care teams that are focused on closing gaps and ensuring patients get better care, and those two things are not always synced up. Even if it's looking at the same area of care, like diabetes management, how they approach that for closing care gaps for their population is separate from all of the work that goes into pulling all that data together from the EMR and reporting. They’re related, but right now because the quality reporting piece is so intensive, there are separate teams and separate strategies, and ideally it should be one approach — and that what you're doing in the best interest of the patients also serves for quality reporting. I think if we can address some of those interoperability challenges and truly move toward digital quality measures involving multiple data sources, not just one, we'll see those strategies align better.

HCI: I remember NAACOS meetings from several years ago where people were talking about the challenges with eCQMs and providing some pushback to CMS about the timeline for those. Has CMS listened and made adjustments or are people still feeling timeline pressure to do it?

Pittman: One of the changes that they did make in response to that was creating this Medicare CQM reporting approach, which for some ACOs is easier than eCQMs, but for others it's more challenging. I think all ACOs are in this space of evaluating what's going to be the least burdensome way of reporting. We have focused our time with CMS on what are the ways that we can modify the existing requirements to make it a little bit better. One example is around data completeness. Instead of having to report on 100% of all beneficiaries, let's lower that. When hospitals first had to report, eCQMs years ago — and they’re reporting from just one EMR — they started at 50% data completeness. We’re starting really high, so let's lower the data completeness requirement. 

HCI: The letter also mentions the WISeR and ACCESS models, and says, “Hey, let's do some of that in MSSP.” What are some elements from those models that might work well in MSSP?

Pittman: ACCESS is as a model of paying for technology, and some of this is already happening in the ACO space. We just don't see it from a billing perspective, because this is where ACOs are leveraging their shared savings to make investments. But given the opportunity to be able to have payment for it, ACOs would take that approach. Many of our members are working with folks who are applying to ACCESS. We also think there's a pathway for the ACO to be the entity doing the tech-enabled service as well. 

On the WISeR front, we have ACOs that are on the hook for a lot of fraud, waste and abuse. And in the past year, we have seen significant fraud in the areas of skin substitutes and catheters. First, we really want to have CMS remove fraud, waste and abuse for which ACOs are not accountable from their expenditures. Beyond that, ACOs are great partners to the federal government in identifying fraud, waste and abuse. We have countless stories from our members. They have beneficiaries come to them saying I don't understand this EOB. The ACO then calls the vendor, drives by the vendor’s location to realize that they are like a mailbox business. So our ACOs are doing the groundwork, and we think there's a way that we can better leverage ACOs in proactively fighting fraud, waste and abuse. Some but not all of the aspects of WISer — like pre-payment review of claims — that could be something that ACOs could take on as well. 

HCI: The letter talks about benchmarks and addressing the “benchmark ratchet.” Can you explain what the benchmark ratchet is and how it can be addressed?

Pittman: Essentially, there are two types of benchmark ratchets that occur in the program. One is for the individual ACO. When an ACO renews its contract, their benchmarks are reset. All of the good work you did in the prior five-year contract now is a penalty to you, because your benchmarks just got lower. So if you created 20% savings in your prior contract, your benchmark starting place is now 20% lower. 

Now that we are many years into the program, and ACOs are on their third or sometimes fourth rebasing, these are significant cuts. It's not a big deal in your first rebasing, but it becomes a much bigger deal over time. So that's the ACO-level benchmark ratchet. 

There is this concept as well of the overall program ratchet. Now that we're 50% of traditional Medicare, the overall benchmark ratchet occurs when you don't have regular fee-for-service spending to bolster your trend updates from a national perspective. 

There are different opportunities to address each one of those. We want to see a higher shared savings add-back to the baseline benchmark at contract renewal. There's one in there now, but we want to see a higher cap, which will create more opportunity for ACOs. 

From an overall programmatic benchmark approach, CMS created the accountable care prospective trend, which prospectively sets a trend for ACOs. And the intention is that it will create a more predictable benchmark over time and counter this idea that the whole program faces a benchmark ratchet. While we think the policy is noble, it does not have any guardrails on it. When the prospective trend is significantly lower than what we're seeing with overall national trends, it arbitrarily lowers benchmarks. We're asking CMS to re-weight that to zero for last year, and likely this year as well — it’s already looking like it's going to be inaccurate — and then put guardrails on the permanent program on a go-forward basis.

HCI: Have you talked to ACO leaders who've gotten to that third rebasing moment and decided not to continue in the program?

Pittman: We have. We have seen a few members who thought it didn't make sense to stay in MSSP, and they joined ACO REACH instead. It's a constant concern, which is why there's this need to address the benchmark ratchet individually and the programmatic benchmark ratchet.