AMGA Calls for Medicare Shared Savings Program Changes Amid COVID-19

CMS should keep the 2021 application cycle for the Medicare Shared Savings Program (MSSP) open and implement other changes to the program to protect providers from excessive costs incurred during the pandemic, the American Medical Group Association (AMGA) recently urged.

“CMS has instituted a number of changes to support providers and their patients during the national public health emergency,” CEO Jerry Penso, MD, MBA, AMGA president and CEO, in a press release. “But the work to move our delivery system to one that prioritizes value needs to continue. We cannot afford to pause the progress that we have made in the transition to value-based care, and cancelling the 2021 application cycle for the MSSP will unnecessarily inhibit that transition.”

The voluntary nature of the program means that only providers who believe they can succeed in the large accountable care organization (ACO) model will chose to apply, added Penso in a letter to CMS Administrator Seema Verma.

“Depriving these groups of the choice to participate in the MSSP in performance year 2021 delays their ability to learn how to deliver care in a value-based model,” Penso reasoned.

Industry leaders have long expressed concerns about MSSP participation rates, especially since CMS overhauled the program in 2018. Earlier this year, CMS reported it approved applications for 53 new entrants in 2020. However, a closer look by the National Association of ACOs (NAACOS) put that number closer to 35 after it determined that some of the “new entrants” had participated in the MSSP before.

“We were disappointed with the numbers in terms of the new ACOs entering into the program, which is a much lower number than we used to see in previous years,” Allison Brennan, senior vice president of government affairs at NAACOS, told RevCycleIntelligence at the time.

On average, the MSSP has seen approximately 100 new ACOS a year. That be challenging to maintain, Brennan stated, but new entrant numbers fell dramatically in 2019, too.

Like AMGA, Brennan worried that lower new ACO participation may affect the industry’s transition to value. Now, the effects of COVID-19 has had on providers is bringing that concern to new heights.

“[W] are concerned about what the impact of forgoing an entire cohort of new ACOs will have on the viability and strength of the program,” Penson wrote.

In the letter to Administrator Verma, Penso also outlined other changes AMGA would like to see made to the MSSP to account for the COVID-19 pandemic.

Firstly, CMS should reverse its decision to allow MSSP ACOs in the BASIC track to remain in their current participation track for an additional year then skip a level the following year, AMGA advised.

The association pointed out that, while the waiver gives ACOs flexibility during the COVID-10 pandemic, it could harm, for example, BASIC Level B ACOs to bypass Level C to enter a risk-heavy track for the 2022 performance period.

“Because groups have had to divert resources to address the COVID-19 pandemic, these providers have not had adequate time and experience in risk-based arrangements,” the letter stated. “These groups need extra time to learn how to operate in these arrangements, and allowing them to progress through to the next level they would have participated in after deferring allows that.”

Additionally, AMGA recommended that quality measures for performance year 2020 be pay-for-reporting.

“We contend that some measures will be difficult to satisfy if patients are not engaging with their providers in office or via telehealth, which is likely due to the current pandemic,” the association explained. “Additionally, the restriction on elective procedures may make it difficult for patients to get their breast cancer, colon cancer, and other various screenings. This problem could get worse if we see a resurgence of COVID-19 in the fall.”

Telehealth implementation during the pandemic also complicates quality reporting for ACOs, the association added.

CMS has already implemented a COVID-19 flexibility that includes services provided virtually, through telehealth, virtual check-in, e-visit, or telephone, in the definition of “primary care services” used for beneficiary attribution.

The agency designed the flexibility to “further allow for the continuity and coordination of care.” However, the flexibility has caused concern among AMGA members that the expanded definition will have unforeseen consequences.

“Some practices currently are attracting new patients due to CMS’ expansion of payment for telehealth services,” the letter explained. “This expansion may result in having a patient attributed to a practice’s ACO through a telehealth visit and the practice subsequently becoming responsible for the cost and quality of care of that patient, who may not continue to see that practice’s physicians once the pandemic ends.”

“We urge CMS to monitor and consider the unanticipated impact of this revision and ensure that ACOs had a meaningful relationship with patients assigned to them. CMS also should clarify the codes that will be used for ACO assignment,” AMGA advised.

Finally, AMGA recommended that CMS make longer-term changes to MSSP benchmarking and regional adjustments to protect ACOs from the anticipated lingering effects of COVID-19.

“Instead of looking at performance over a single year, AMGA would be interested in working with CMS and other stakeholders to develop a benchmarking and financial reconciliation process for ACOs that spans multiple years,” the association stated.

For the short term, AMGA suggested that CMS assess whether the current regional factors for benchmarking are appropriate for ACOs functioning during a pandemic. COVID-19 has led to significant variation in spending and utilization in the program, AMGA explained, and it remains unclear if the program’s current limit on regional adjustment and retrospective application of the historical benchmark will “reasonably account” for these trends.

“Specifically, CMS should evaluate whether the 5 percent cap of the regional adjustment is sufficient or it needs to be increased,” AMGA stated.