Organizations Pen Letter to CMS Administrator Asking to Extend MSSP Track 1

In a joint letter, a group of organizations urged CMS Administrator Seema Verma to allow certain accountable care organizations (ACOs) to continue in the Medicare Shared Savings Program (MSSP) Track 1 for a third agreement period before having to move to a 2-sided risk model.

According to the letter, some ACOs are not ready to take on a 2-sided risk: “Many ACOs remain in Track 1 because they are unprepared to assume risk requiring them to potentially pay millions of dollars to Medicare, which is simply not practical or feasible for most of these organizations,” wrote the organizations.

The organizations — National Association of ACOs, American College of Physicians, American Medical Association, Association of American Medical Colleges, Medical Group Management Association, and Premier Healthcare Alliance – also point out that providers in rural areas and safety-net providers, which both care for some of the most vulnerable patients, often face greater challenges than other providers when considering taking on risk.

MSSP Track 1 represents 82% of MSSP ACOs in 2018, as it continues to be the most popular option for ACOs. As ACOs are able remain in Track 1 for 2 agreement periods, those that began the MSSP in 2012 or 2013 entered their second agreement period in 2016 and are on track to schedule their third agreement period beginning in 2019, representing the first time ACOs will be required to enter a 2-sided agreement.

The organizations note that these are the first ACOs to join MSSP and that they have shown significant dedication to the ACO model, embracing MSSP early on and working collaboratively with each other and CMS to help shape the program.

“These ACOs have faced a number of challenges, some of which have been addressed by CMS through regulatory changes, but many program modifications are still needed,” wrote the organizations. “The MSSP and these ACOs have evolved considerably, creating a shifting landscape for these early adopters. In order for ACOs to make a thoughtful business decision to assume risk, they need predictability and positive performance results.”

The letter argues that these ACOs need more time to prepare, and while 6 years seems like sufficient time, it is not enough. When the ACOs make their decision about participating in 2019, they will have performance data available for 4 performance years. Based on the evaluation of the 4 performance years, the organizations push for CMS to allow Track 1 ACOs to meet at least 1 of the following criteria to continue in Track 1 for a third agreement period:

• ACOs that generate net savings across 4 performances years
• ACOs that score at or above the 50th percentile in quality in 2 of the 3 pay-for-performance years
• ACOs that improve their overall quality score by 10 percentage points or greater over the course of pay-for-performance years
• ACOs with spending that is lower than that of their region

The organizations concluded the letter by warning that Track 1 ACOs not ready for risk will not move forward and will quit the program, and “using a government mandate for risk is not the solution to increasing participation and achieving successful results for 2-sided ACOs.”

Shortly after CMS announced that 561 ACOs would be participating in MSSP in 2018, Clif Gaus, ScD, president and CEO, National Association of ACOs, said that the increase in number of ACOs participating in 2-sided models is an encouraging sign, while also noting that it is important to recognize all the time and effort needed for these ACOs to be ready to assume risk. Gaus also noted a need for improvements to the program in order to provide stability and demonstrated success so that ACOs will feel confident in entering 2-sided risk.