Kim Kauffman on ACOs Considering Medicare Advantage Over Pathways to Success

Note: Since this video was filmed, CMS has finalized its overhaul of the Medicare Shared Savings Program. Read more about the final rule.

As CMS prepares to implement its new Pathways to Success program (formerly Medicare Shared Savings Program) for accountable care organizations (ACOs), some ACOs may consider Medicare Advantage a more beneficial arrangement, explained Kim Kauffman, MPH, vice president of value-based care at Summit Medical Group.

Transcript

Do you think CMS’ Pathways to Success might make some ACOs leave the Medicare Shared Savings Program (MSSP) and consider Medicare Advantage?

Oh, that is a hot topic, that is a hot topic in this conference [fall meeting of the National Association of ACOs]. I think that Pathways to Success represents significant changes—some of which are really good and some of which are very concerning. The effect of those changes is going to vary quite a bit based on the individual ACO. Are they brand new to the program, are they considering getting in the program or are they more mature? Maybe they already have some downside risks, so I think the impact of the proposed changes really will vary ACO by ACO.

For a brand new ACO or somebody contemplating coming into the program, the change from downside risk after 2 years versus now where they’ve got up to 6 years would be daunting. I personally would not likely recommend that my organization jump in and have downside risk after 2 years, and then can add on to that the fact that the sharing rate is only 25%, and so based on our calculations it will take the typical physician-led ACO, which has lower overhead, years and years—and we’re talking 4 or 5 years—before they would likely break even on the operational expenses. So, it’s a concern; it’s concerning to me.

Medicare Advantage, in my experience, allows for longer on ramps to downside risk and, of course, the sharing rates both up and down are negation points and therefore, reflect the local nature of healthcare. And not all patients want to move into Medicare Advantage. The country, I believe, needs a solution for patients who want to remain in traditional Medicare. MSSP ACOs are that pipeline for that and transformation takes time, so I’m really hopeful that CMS will listen with an open mind to all of the comments and take into consideration the fact that we need a pipeline to transform care and that it takes time to change care.