- CMS should evaluate the impact of a new rule for the Medicare Shared Savings Program on accountable care organizations' ability to achieve cost and quality outcomes as well as their willingness to participate in the program, according to the HHS Office of the Inspector General. Finalized in December, the rule cut the time ACOs participating in MSSP had to avoid taking on downside financial risk.
- OIG also suggested CMS adopt outcomes-based performance measures whenever possible — rather than process measures — and standardize measures across programs.
- The watchdog department also said CMS should evaluate the effectiveness of a waiver that gives some ACOs more flexibility over when they send patients to a skilled nursing facility. Based on the results of the analysis, CMS might expand the use of the waiver in MSSP as well as other alternative payment models, according to the report.
To arrive the seven recommendations, the OIG interviewed 20 high-performing ACOs in MSSP about the strategies they use to provide high-quality patient care and reduce costs.
The strategies that the OIG found to be successful include increasing physicians' awareness about the costs of tests and treatments, engaging patients in managing their health, tightly managing care for medically complex patients, focusing on behavioral health issues and social determinants of health and deploying technology to promote information sharing among providers.
ACOs are often credited with achieving positive results, such as reducing costs, hospital readmissions and emergency department visits. The OIG's 2017 report on MSSP found that high-performing ACOs reduced Medicare spending by an average of $673 per beneficiary.
Last year, 561 ACOs participated in MSSP, serving 10.5 million Medicare beneficiaries.
Most ACOs in the program are in contracts that allow them to earn a portion of the savings they generate in Medicare spending. Fewer ACOs assume downside risk, in which they are also accountable if they don't generate savings.
The rule to move ACOs into downside risk contracts faster cut in half the time organizations have to avoid taking on risk. New ACOs in the program must assume risk in two years, while low-revenue ACOs have three years.
ACOs have been wary of assuming financial risk in MSSP. The National Association of ACOs, an advocacy group, released a study last year finding nearly three-fourths of the organizations would leave MSSP this year if forced to assume financial risk.
To entice them to take on more financial responsibility, CMS gives these ACOs more flexibility in how they manage their patients. For example, they can send their patients to skilled nursing facilities whenever they think it is medically advisable. Under standard CMS rules, Medicare patients are eligible for skilled-nursing stays only after spending at least three days in a hospital.
In its report, the OIG said the three-day rule may lead to unnecessary hospitalizations. It recommended CMS evaluate how ACOs performed when they were given the flexibility to waive the rule, and to apply the results of the analysis to updates to MSSP or other programs.
The OIG also said it recommended that CMS adopt outcomes-based measures whenever possible because research suggests some process measures — which typically track how often providers follow a given treatment guideline — may add to costs without necessarily improving health outcomes.