NAACOS: Medicare Shared Savings Program Needs Full-Risk Option

A full-risk option in the Medicare Shared Savings Program (MSSP) would offer accountable care organizations (ACOs) additional flexibility and more capitation options, according to the National Association of ACOs (NAACOS).

In a blog post, David Pittman, director of communications and regulatory affairs at NAACOS, shared how a full-risk track in MSSP would provide a better bridge to the ACO REACH (Realizing Equity, Access, and Community Health) model.

MSSP currently offers six tracks of varying risk levels, but no full-risk option exists. The highest risk option available, the Enhanced Track, allows ACOs to share 75 percent of shared savings or losses.

NAACOS has requested that CMS offer a full-risk track, which it calls Enhanced Plus. The name references the Enhanced Track and the retired Track 1+ option. The blog post also noted that another option is needed between the Enhanced Track and the full-risk track, a path that is only available under the Global option of ACO REACH.

According to Pittman, the Enhanced Plus option should include 100 percent shared savings and loss rates and allow participation at the individual level instead of the hospital or practice level. In addition, the track should include options for population-based payments that range from partial to full capitation with the ability to negotiate value-based payment arrangements with downstream providers.

The ideal full-risk option would apply a regional-only benchmarking trend to reflect local market changes and offer advanced waivers, such as post-discharge home visit waivers, care management home visit waivers, and Part B cost-sharing support.

A full-risk track has only been available in CMS Innovation Center models. More than a third of all MSSP ACOs participate in MSSP’s Enhanced Track, indicating that ACOs are willing to take on more financial risk. If the Enhanced Plus option incorporated elements only available in Innovation Center models, more ACOs could innovate and improve patient care quality, Pittman said.

In the calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS), CMS included a request for comment on a higher-risk track in MSSP.

The agency said only ACOs with proven success may be interested in the option, potentially leading to more shared savings payments and less savings for CMS. Therefore, the agency may need to reconsider ACO protections, including the cap on shared savings and losses. Additionally, CMS noted concerns that ACOs would avoid high-cost patients.

“But it’s a positive sign that CMS is seeking comment on our calls and thinking harder about expanding the menu of options for ACOs as it works to reach its goal of having all Medicare beneficiaries in an accountable care relationship by 2030,” Pittman wrote.