The proposed 2015 rules for Medicare B payments add a dozen new quality measures and patient outcome-based metrics, including unplanned admissions for patients with diabetes, heart failure, or multiple chronic conditions.
With the Medicare Shared Savings Program preparing to enter its fourth year in 2015, federal officials are recasting the list of quality metrics and providing "bonus payments" to incentivize year-to-year performance gains.
The Centers for Medicare & Medicaid Services' proposed rules for 2015 payments through Medicare B, which covers outpatient care, include several changes to the Medicare Shared Savings Program. With more than 300 healthcare organizations participating, MSSP is the largest of two accountable care programs CMS administers, in part because it is a risk-bearing contract with no downside. In the other one, CMS's Pioneer ACO program, participants benefit from gain-sharing but also face the risk of cost-sharing.
The proposed Medicare B rules both refresh and cull quality measures. A dozen new quality measures add patient outcome-based metrics to the list, including unplanned admissions for patients with diabetes, heart failure, or multiple chronic conditions.
The proposed quality measures also include post-discharge tracking of hospital patients to see whether they are admitted to skilled nursing facilities within 30 days of discharge.
Eight of the 33 MSSP quality measures that were adopted in 2011 are slated to be scrapped, mostly because they were considered redundant or out of step with best clinical practices. If CMS moves forward with its proposed changes, there would be a total of 37 MSSP quality standards next year, a net gain of four standards over the current year.
"We believe the measures chosen are more outcome-oriented and would ultimately reduce the reporting burden on ACOs," CMS officials say in the proposed rules.
Tomas Mikuckis, a principal specializing in health and life sciences at New York, NY-based management consulting firm Oliver Wyman, says there are "three notable trends" in the quality measures set to be added to MSSP:
- An increasing focus on patient outcomes rather than process measures, which will require ACOs to increasingly demonstrate that their activities are having measurable impacts on patient health
- The emphasis on chronic condition management, which "makes a lot of sense" given the large prevalence of chronic conditions in the senior population and the disproportionate impact these conditions have on health costs
- The skilled nursing facility measure could demonstrate CMS's willingness to hold the ACOs accountable for patient care across care settings and even at providers that are not formally part of the ACO
The proposed Medicare B rules also seek to provide incentives for MSSP ACOs to improve their quality measure scores from year-to-year. The incentives would be provided in addition to the program's standard gain-sharing calculation mechanism.
"ACOs that demonstrate quality improvement on established quality measures from year to year will be eligible for up to 2 bonus points per domain," say the proposed rules.
Paul Clark, a legal analyst at Wolters Kluwer, says the incentives for annual improvement indicate CMS are both determined and flexible in the agency's efforts to optimize MSSP.
"CMS is proposing to reward not just ACOs that meet the existing quality measures, but that show year-to-year improvements in specific areas. This 'explicit incentive,' in CMS's words, is to emphasize that meeting quality goals is not a static, one-time result, but an evolving process," he says. "This is one of the reasons CMS is changing the MSSP quality measures on a regular basis."
The deadline for healthcare industry stakeholders to comment on the proposed changes to 2015 Medicare B payment rules, including ACO regulations, is Sept. 2. CMS officials have solicited comments on several possible new MSSP quality standards such as care coordination, prevention and utilization.
Mikuckis says federal officials appear to be gearing the MSSP model of accountable care for the long haul.
"Taken as a whole, the rule changes and the request for comments seem to point to the fact that MSSP is on a path toward trying to drive further improvement and impact in ACO performance, and increasingly transitioning to a broad range of quality outcomes metrics that reflect the main priorities that ACOs should focus on in improving population health," he said.
"Additionally, some of the minor tweaks to align metrics and measures with those used in other CMS initiatives are a good indicator that the program is here to stay, and that CMS will have a desire to continue to grow the number of Medicare beneficiaries that it covers."
Provider Reaction
Healthcare providers appear to find MSSP intriguing, but modest levels of gain-sharing so far have them pushing for more benefits.
"Our reason to enter this program was to dip our toe into a risk-bearing contract," says Jonathan Nasser, co-chief clinical transformation officer at Middletown, NY-based Crystal Run Healthcare, one of the first 27 MSSP ACO participants. "We viewed it as a learning experience, which has been a success."
Now that it has climbed the accountable care learning curve, Crystal Run would like to see a higher level of gain-sharing, Nasser says, adding that his organization has yet to realize any significant revenue from participating in MSSP.
"It feels like the deck is stacked against the ACOs to actually see gain-sharing," he said, adding Crystal Run had faced several MSSP challenges such as embracing data analytics. "It definitely was a lot of work."
Melissa Jackson, a senior associate director in policy at the American Hospital Association, says providers need to be able to achieve greater gain-sharing if CMS wants its Medicare ACO programs to expand in the future. "We have pushed CMS to increase the amount of benefits ACOs are able to achieve," she said. "[Providers] have to make significant financial investments on the front end to improve care… The target thresholds need some adjustment."
Akin Demehin, who also serves as a senior associate director in policy at the AHA, says the proposed changes to MSSP quality standards are welcomed "in general" but need to be crafted carefully.
"The challenge is making sure those measures are adjusted for things that are out of the control of the provider," he says, adding that MSSP quality measures need to account for fundamental differences between patients such as severity of illness and socio-economic factors. "For most outcomes measures, performance is driven not just by care but also by clinical conditions."
As he looks to the future, Nasser says MSSP ACOs such as Crystal Run will eventually hit a gain-sharing ceiling.
"Accountable care is definitely here to stay because CMS is moving to value-based care delivery," he said. "But you can't continue to share savings forever. … We think over the long-term this will move to something more like Medicare Advantage and capitation."
Christopher Cheney is the CMO editor at HealthLeaders.