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June 16, 2021 The Honorable Chiquita Brooks-LaSure Dear Administrator Brooks-LaSure: The National Association of ACOs (NAACOS) congratulates you on your confirmation as administrator of the Centers for Medicare & Medicaid Services (CMS). NAACOS and our members are deeply committed to advancing value-based care. As the administration looks to address difficult Medicare solvency issues made worse by the recent pandemic, we stand ready to help you continue to drive forward a healthcare system committed to serving not only patients, but also the health of the community as a whole, through successful value-based models such as the accountable care organization (ACO) model. NAACOS represents more than 370 ACOs participating in a variety of value-based payment and delivery models in Medicare, Medicaid, and commercial insurers. Serving more than 12 million beneficiaries, our ACOs participate in models such as the Medicare Shared Savings Program (MSSP), the Next Generation Model, the Direct Contracting Model, and other Alternative Payment Models (APMs). NAACOS is a member-led and member-owned nonprofit organization that works to improve quality of care, health outcomes and healthcare cost efficiency. ACO models continue to be one of the most successful value-based models, reaching a significant number of Medicare patients. The MSSP, the largest of the ACO programs serving 11.2 million beneficiaries, continues to produce greater savings each year. In 2019, the most recent year for which data is available, the MSSP saved Medicare $2.6 billion total, and $1.2 billion after accounting for shared savings/loss payments to participants. Importantly, this model continues to advance the movement to value-based care and is the APM accounting for the largest number of participants in Medicare’s Quality Payment Program (QPP). To build on the success of the ACO model and to strengthen primary care and patient-provider relationships, we recommend that CMS set a national goal to have a majority of traditional Medicare beneficiaries in an ACO by 2025. NAACOS and its ACO members are committed to continuing the advancement of value-based care and improving health outcomes with high-value care. However, the ACO model has faced significant challenges in recent years, with participation in the MSSP declining. To encourage growth in these important programs and models, we urge CMS to make several modifications to ensure the ongoing success of ACOs, and therefore continued savings to the Medicare Trust Fund and improved outcomes for the Medicare beneficiaries they serve. Given the success of the ACO model and the need to strongly support the ongoing transition to value-based care and payment, we request CMS recalibrate the balance of risk and reward for ACOs to bolster ACO program growth, and, as a result, savings to Medicare. Among those changes, we request that CMS reverse certain policies finalized in a 2018 MSSP overhaul, which CMS named the ACO “Pathways to Success.” This overhaul included some damaging provisions such as a cut to the share of savings many ACOs are eligible to keep as well as a push for ACOs and their providers to assume financial risk too quickly. As evidenced by declining ACO participation in recent years, these policies have chilled ACO growth, and we request modifications to restore program growth. We also recommend that CMS focus the value transition squarely on providers, keeping them at the center of payment models instead of implementing programs and policies to attract new players into the traditional Medicare space. Our specific recommendations for restoring robust participation in the premier value-based model are detailed below. Items Requiring Immediate Action
Detailed Recommendations on Items Requiring Immediate Action Make Adjustments to Quality Reporting and Assessment Changes While reducing the number of measures and leveraging electronic data sources for quality reporting are important goals, we have significant concerns about the MSSP quality policies finalized in December of 2020. The policy changes lacked adequate input from the patient, ACO, physician and hospital communities, and it is unclear how CMS determined that the Alternative Payment Model Performance Pathways (APP) measures are more appropriate than the current measures on which ACOs are evaluated. Furthermore, the ACO and vendor communities lack key guidance and details necessary to implement the move to reporting of electronic clinical quality measures (eCQMs) and Merit-Based Incentive Payment System (MIPS) CQMs in the unrealistic timeline required by CMS. We believe there is an important opportunity for CMS to revise aspects of the recently finalized MSSP policies to better support ACOs and promote high quality patient care. Specifically, we urge CMS to delay mandatory eCQM and MIPS CQM reporting for at least three years while the agency further explores the costs and implications of these changes. Additionally, CMS should seek additional input on the MSSP quality measure set, such as through the Measures Application Partnership (MAP) to identify the ideal measure set to continue to drive quality improvement through the MSSP. We also have significant concerns with CMS’s decision to broaden reporting and evaluation to all payer data. This is technically difficult for ACOs, which often lack access to this data, and this requirement would evaluate ACOs on patients they may not have contractual agreements to serve. It is unfair to make such a significant change of this manner mid-contract, particularly now that more ACOs than ever have been accelerated to bearing financial risk for their participation in this model. Instead, we urge CMS to limit ACO reporting and evaluation to ACO assigned beneficiaries, as has historically been the case for MSSP. Our detailed letter on this topic sent to the agency earlier this year is available here and includes 11 additional leading healthcare associations who also share our concerns. Adjust 2022 ACO benchmarks to account for anomalies from the COVID-19 pandemic and fix ongoing benchmark issues such as the “rural glitch” and risk adjustment flaws We also urge CMS to correct the MSSP benchmarking issue known as the “rural glitch” to more appropriately evaluate ACO performance. The current method compares an ACO’s spending to a blend of its historical spending and regional spending. However, including the ACO in the regional component makes it necessary for the ACO to ‘beat’ its own performance twice, thus defeating the purpose of using a regional comparison. This is particularly problematic when an ACO makes up a large portion of a particular area, which is often the case for ACOs in rural areas. Another problematic MSSP methodology that should be addressed is an inconsistency between how CMS handles risk scores for ACOs compared to their region. Specifically, CMS has a policy where the risk score for an ACO’s eligibility category cannot increase more than three percent from its most recent benchmark year. For example, an ACO that started in 2019 could have a risk score in the aged/dual eligible category of 1.00 in 2018 and that risk score is not permitted to increase beyond 1.03 through 2024. While NAACOS advocates to increase the three percent cap over five years to a cap of no less than five percent, a more pressing change is to have CMS consistently apply a risk score cap to the region’s risk score. Currently, there is no cap on the region’s risk score, which unfairly penalizes ACOs. The COVID-19 pandemic introduced increased variation, and data show situations where a region’s risk exceeds the cap, essentially creating an automatic penalty for ACO in that market which cannot exceed the cap. While many, including CMS, did not anticipate this situation from occurring often, it is important to take swift action to fix this and establish fair and consistent policies for ACOs. We urge this policy be fixed retroactively, starting with performance year 2020. Increase the Onramp for Assuming Risk to Encourage Widespread Participation Restore Shared Savings Rates to Incentivize Participation Address the Increasing Problem of APM Overlap Develop MSSP “Enhanced Plus” opportunity with full risk and options for capitation
Make Improvements to the Direct Contracting Model Specifically, we recommend CMS take the following actions:
In addition, NAACOS urges the CMS Innovation Center to fully stop the Geographic Direct Contracting Model and the new DCE type that allows Medicaid Managed Care Organizations (MCOs) to manage Medicare fee-for-service (FFS) expenditures for dually eligible beneficiaries. Instead, CMS should introduce appreciated policies worthy of being tested in other APMs. “Geo,” as it’s commonly referred to, would cause undue confusion amongst beneficiaries, and disrupt ACO providers’ established relationships with their patients if a Geo DCE ultimately has financial accountability for traditional Medicare beneficiaries in the region. It would also create concerns about the role of health plans in traditional Medicare and the future direction of APMs within the Innovation Center. NAACOS is concerned an MCO DCE type will bifurcate care for these vulnerable patients. ACOs and DCEs already care for a large number of dually eligible patients, particularly those in long-term care settings. Because patients can only be assigned to one entity, the Innovation Center risks eroding the care already provided to these high-risk patients. Improve ACOs’ Access to Data to Enhance Performance Section 3221 of the Coronavirus Aid, Relief, and. Economic Security (CARES) Act modernizes the privacy of treatment records for substance use disorder (SUD) by creating parity between 42 CFR Part 2, which governs SUD privacy, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As the Department of Health and Human Services (HHS) works to implement the CARES Act, we urge you to address the important issue of claims and data access for providers practicing in APMs. ACOs, for example, are provided claims data at least monthly, and sometimes weekly, through Claim and Claim Line Feed (CCLF) files, but these data lack SUD-related information because of the limits of Part 2 law. Without access to such claims data, ACOs and other APM participants risk treating the whole patient with only part of their data, potentially harming patient care and outcomes. By aligning Part 2 with HIPAA, the CARES Act allows sharing of this important data after initial patient consent, which will allow CMS to deliver this critical information to providers operating in ACOs. We urge you to work with your HHS partners to send SUD-related claims data to providers practicing in APMs to help support their work in population health management. CMS’s HIPAA Eligibility Transaction System (HETS) allows providers to check Medicare beneficiary eligibility in real-time using a secure connection. CMS should make HETS feeds available to ACOs and Medicare providers participating in APMs to better understand, in real-time, where patients seek care in the health system. ACOs’ access to critical HETS information in real time would allow ACOs to further enhance care coordination, improve patient outcomes, and reduce costs — all are tenets of advancing value-based payment models. NAACOS developed, with the assistance of technical experts, an outline for an ACO Inquiry Notification System. The system, operated by a registered third party, would serve as a secure, point-of-service notification system. Leveraging real-time data feeds from HETS, the notification system would alert ACOs when one of their assigned patients may be seeking care or receiving services outside their ACO. This would limit customization and provide a simplified, user-driven approach to extract data from the current HETS system. Alternatively, CMS could allow Medicare ACOs the ability to securely access the system independently and monitor for their patients. Modernize Telehealth Requirements Remove the Burdensome Beneficiary Notification Requirement Longer-term Issues
Conclusion In conclusion, we stand ready to work with CMS under your leadership to further advance value-based care for all Medicare patients. NAACOS and its members are committed to providing the highest quality care for patients while advancing population health goals for the communities they serve. We would like to meet with you and your staff to discuss these recommendations and how NAACOS can support your efforts to improve health equity and advance value-based care for all Medicare patients. Allison Brennan, Senior Vice President of Government Affairs, will contact your office to formally request a meeting, she can also be reached at 202-725-7129 or [email protected]. Sincerely,
Clif Gaus, Sc.D. |
