October 10, 2024 – For several years, the Center for Medicare & Medicaid Innovation (CMMI) within the Centers for Medicare & Medicaid Services (CMS) has been working towards a goal it set in 2021 to get all Medicare and the vast majority of Medicaid beneficiaries in “a care relationship with accountability for quality and total cost of care” by 2030.
Last week, leaders at CMMI and within CMS provided an update on this goal and how they are using lessons learned from accountable care initiatives to improve the overall Medicare program. So the question to consider today is: What has CMS done, and what does the agency plan to do going forward to promote accountable care?
To help provide some perspective on this issue, I’m bringing in my new colleague Simeon Niles. Simeon brings to our team years of experience working in the value-based care space, including serving at CMMI, so I can’t think of anyone better to help us digest CMS’s plans.
CMMI was established by the Affordable Care Act (enacted in March 2010) and since its inception has tested more than 50 alternative payment models. However, the Affordable Care Act created strict restrictions on when those models can be expanded. Generally speaking, models can be expanded if the chief actuary at CMS and the secretary of the US Department of Health and Human Services determine through an evaluation that the model:
- Improves quality and reduces cost;
- Improves quality and is cost neutral; or
- Reduces cost but does not reduce the quality of care.
Not many models have met the criteria for expansion, but that hasn’t stopped CMS from incorporating lessons learned from CMMI models into traditional Medicare. One example is the creation of a downside financial risk option in the national accountable care organization (ACO) program, the Medicare Shared Savings Program (MSSP), based on the experience of multiple ACO initiatives, including the Pioneer ACO model and the Next Generation ACO Model. CMMI also has incorporated advanced shared savings payments into MSSP and made certain benefit enhancements more widely available.
However, even though some models have been successful, translating those successes into permanent policy changes has been a slow process. CMS’s recent rulemaking and comments in the physician fee schedule (PFS) highlight the agency’s objective to be more intentional in scaling up CMMI innovations. CMS argues that incorporating lessons into existing CMS programs not only advances its goal of having all Medicare fee-for-service beneficiaries in accountable care by 2030, but also brings stability and consistency to providers that want to continue using successful care strategies without the uncertainty of time-limited models.
Although CMS has been attempting to chart a path forward for accountable care models, stakeholders overall have stated that they still want additional clarity. Clinicians, physician groups, and health systems participating in CMMI’s ACO REACH model are particularly eager to know what happens once the model ends on December 31, 2026. These stakeholders have asked CMS to develop a higher risk track within MSSP so that they can continue improving quality and reducing costs once ACO REACH ends. In the CY 2024 PFS proposed reg, CMS sought feedback on the possibility of introducing a higher risk track with shared savings/loss rates between 80% and 100%, which would go beyond the current MSSP ENHANCED track’s maximum of 75%. The feedback received from stakeholders highlighted a strong interest in a higher risk track. Many participants noted that such a track could encourage more ACOs to take on advanced levels of risk and reward, promoting innovation in care delivery and specialty care integration. CMS acknowledged these comments in the final CY 2024 reg and noted that it would use this input to inform future rulemaking. However, CMS still hasn’t committed to a path forward. CMS also sought comment on this same topic in the CY 2025 PFS proposed reg and did not propose an actual solution. The continued lack of a concrete policy means that ACOs currently participating in models such as ACO REACH must wait a bit longer for more definitive guidance on how they can continue to align their efforts and maximize their return on investment. Without clarity on what to expect in future rulemaking, these organizations believe that they will be unable to effectively plan how to appropriately target their resources, risking potential setbacks in strategic investment and long-term care redesign.
Going forward, CMMI could take additional steps to further support integration of innovation successes into traditional Medicare. The agency could establish a more formalized and structured process for integrating successful innovations into permanent Medicare programs. While CMS has made progress by incorporating lessons learned from CMMI models, the current approach relies heavily on the agency first signaling intent through already crowded and complex proposed regs. By establishing a clear, actionable roadmap and criteria for when and how the agency will integrate proven models or model elements into core Medicare programs, CMS could perhaps provide a clearer trajectory for value-based care adoption and reduce the uncertainty for providers.
Just some food (eggs) for thought on CMS’s accountable care strategy going forward!
Until next week, this is Jeffrey (and Simeon) saying, enjoy reading regs with your eggs.
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