ACO Learning Network Comments on the Proposed Rule for the Medicare Shared Savings Program

Mark B. McClellan
Mark B. McClellan Former Brookings Expert, Director, Margolis Center for Health Policy - Duke University

February 6, 2015

The ACO Learning Network believes that models that align quality care and payment are critical in supporting providers in delivering the best possible care to their patients, especially in an era of increasingly personalized and prevention-oriented medicine. The goal of Accountable Care Organizations (ACOs) remains the same as it has been— enable physicians, hospitals, and other health care providers to get the support they need to deliver high quality care to patients and lower overall health care costs. The Medicare Shared Savings Program (MSSP) has been an important catalyst for transforming health care systems of varying sizes in all parts of the country.  While early results show that these organizations have improved quality in many areas, only a quarter of the MSSP ACOs have been able to reduce spending enough to share in savings generated from their efforts. Further refinements to the MSSP are necessary to ensure the long-term sustainability and success for both individual organizations as well as the program.

We believe that the Notice of Proposed Rulemaking (NPRM) released on December 1, 2014 begins to address many of the pressing challenges that have arisen in early experiences, and we appreciate the openness from the Centers for Medicare and Medicaid Services (CMS) in soliciting further reform ideas through the NPRM.  The breadth of issues presented, the critical juncture at hand for the Medicare ACO program, and the other reforms taking place throughout the health care system means that the final rule will have implications not only for the MSSP but also the overall Medicare program and the US health care system. We believe that there are a number of areas in the proposed rule that need further refinement in order to ensure success going forward for the program and the wider health care system. In particular, we think CMS should use the NPRM process to strategically align the program with other payment reforms and performance measurement systems, a point we emphasize in several places throughout our comments. Our submission focuses on a number of areas addressed in the NPRM, framed in terms of the broader themes that we discuss below. Ultimately, we intend for these comments to help the MSSP achieve the important goals of improved patient care and reduced costs.

Our comments reflect the experience of ACO implementation gained through research, analysis, and communication with many current and prospective Medicare ACOs and participants in private-sector and Medicaid accountable care reforms. The ACO Learning Network is committed to providing participating organizations—including ACOs, other non-ACO providers, payers and purchasers, medical associations and societies, consulting firms, pharmaceutical manufacturers, and other industry stakeholders—with  the tools and knowledge necessary to successfully implement accountable care, and additionally deliver national guidance on practical policy steps. Over the past six years, we have gained significant knowledge from those organizations in all stages of ACO implementation and practice. We have also spoken with many of our members and others to receive feedback on how the MSSP could be further improved. These discussions and analyses inform a large part of the comments we offer below.

The work conducted through the ACO Learning Network and other related activities has demonstrated that the process of becoming and implementing an ACO can be time-intensive, cumbersome, uncertain, and slow. Successful accountable care practice requires the engagement and commitment of providers, payers, and patients.  There is also not a “one size fits all” model for an ACO; organizations have both different starting points and different opportunities to transform care based on their current capabilities. ACOs have seen varying levels of success, driven by a number of different factors: size, scope, and ability to develop effective networks; previous experience with risk-bearing arrangements, experience and ability for physicians to transform care, level of physician and patient engagement, demographic and health status of the patient population, regional differences, and other organizational and market characteristics. In addition, there are a number of other factors that are harder to quantify but may be better predictors of success, such as organizational culture and leadership. Empirical research on which of these factors and combinations of factors are most likely to drive success is still in its early stages. CMS policy choices will have a significant impact on the ability of these diverse organizations to succeed.  Given this uncertainty, it is imperative that the MSSP continue to support organizations of varying size, experience, and other characteristics to determine which can succeed. Payment and regulatory policy should thus provide a path with different starting points to achieve improvements in care, while also meeting the general requirements of MSSP participation.  Further, because success in transforming care requires an ongoing commitment, ACOs need a clear and predictable path forward. Over time, MSSP should develop a stronger capability to help organizations implement effective improvements with more speed and certainty or transition out.

As CMS considers comments from a variety on stakeholders on the proposals set forth in the NPRM, we emphasize the following general principles to ensure the continued success and participation of the MSSP:

  1. Creating greater certainty for program participants
  2. Establishing a clear and achievable transition path to financial risk
  3. Engaging patients
  4. Aligning MSSP with other Medicare payment programs
  5. Taking lessons from commercial ACOs

In all of the areas highlighted above, CMS has the opportunity to continue refining the MSSP with an eye toward what has and has not worked in both public and private sector ACO efforts. Throughout our comments, we highlight the lessons learned by current participants and assess how the regulations can be adjusted to ensure continued participation and success of existing ACOs, as well as new organizations that are committed to using ACO payment reforms to improve care and lower costs. ACOs can be a critical part of greater system-wide support for needed improvements in health care delivery.  Through our experience and conversations with ACOs of all sizes and sophistication across the country, we remain optimistic that CMS can set the MSSP on a more sustainable and successful path by addressing the major concerns we have raised, as reflected in the specific comments that follow. We appreciate your attention to the future of the MSSP and look forward to providing further assistance to CMS in its continued development, implementation, and ultimate success.