AMGA to CMS: Rethink ACO Financial Risk Advancement in MSSP

The American Medical Group Association (AMGA) recommended several steps regarding accountable care organization (ACO) financial risk advancement in the Medicare Shared Savings Program (MSSP) in a letter to CMS.

CMS’ decision to defer the automatic advancement of ACOs in the MSSP and allow ACOs to remain in their current risk level of the BASIC Track’s glide path for performance year (PY) 2022 prompted AMGA to express concern.

The decision extends the policy CMS implemented during the COVID-19 public health emergency in an attempt to create more financial flexibility for ACOs. The unprecedented circumstances of the pandemic called for CMS to give ACOs the option to pause and reassess their risk tolerance.

AMGA’s first recommendation was for CMS to finalize this option that allows ACOs to stay in their glide path position for PY 2022. AMGA voiced some concerns surrounding this policy though.

“As finalized in the May 2020 IFC, ACOs that opted not to automatically advance in PY 2021 will transition to the level they would have reached had they not opted to freeze their participation level in response to the pandemic,” AMGA explained in the letter. “For example, as CMS notes, any ACO that opted to hold its participation at Level B in 2021 will bypass Level C and advance to Level D in PY 2022.”

The policy extension would follow this new rule as well, with ACOs bypassing one level for their new glide path position in PY 2023. If the ACO chose to defer advancement twice, it would then have to skip two levels.

AMGA disapproved of this skip policy and recommended CMS not to automatically advance an ACO to a risk level it is not prepared for. Providers in the ACOs that chose to remain in their level during the pandemic may not be prepared to immediately advance to a level that would present more downside risk than they can handle.

Moving from a one-sided risk level, such as Levels A and B, directly to a two-sided arrangement like Levels D and E, goes against the intent of the BASIC Track’s glide path, according to AMGA’s letter. The glide path was designed to help ACOs transition into increased levels of risk over time. But the advancement requirement does not support gradual progression and instead forces providers into risk-based situations they are not prepared for.

AMGA’s final recommendation regarded the timeframe that CMS provided in which ACOs will have to decide whether to remain in their current level or advance in the glide path. CMS has not provided a concrete deadline for the decision, however based on the information they have announced, ACOs will have a small timespan to assess several factors pertaining to their decision. AMGA suggested that CMS present a clearer timeframe for ACOs to work with.

AMGA also expressed concern regarding the lag between the end of a performance year and the time when CMS provides important data to ACOs that can help them evaluate their risk tolerance.

“If the rule is finalized, an ACO will receive the prior year’s final report during the third quarter of 2022. The ACO then would be required to advance two stages without fully being able to evaluate what these reports mean for the ACO,” AMGA wrote in the letter. “Less mature ACOs might be less equipped to quickly evaluate, project, and develop strategies based on these reports. Finalizing this policy also might deter less mature ACOs from staying in the program.”

AMGA urged CMS to adjust its current policy surrounding ACO advancement in the MSSP before finalizing anything in order to ensure risk management success. This adjustment may be necessary to keep ACOs in the MSSP, especially with participation numbers at an all time low in 2021.