What are the key revisions to the proposed “Pathways to Success” rule?

On December 31, 2018, the Centers for Medicare and Medicaid Services (CMS) published the final rule for the 2019 Medicare Shared Savings Program (MSSP). This rule finalizes many of the “Pathways to Success” provisions detailed in the proposed rule published on August 8, 2018, with some modifications that may have a major impact on a number of accountable care organizations (ACOs). At its core, the final rule creates a structured timetable for inexperienced ACOs to transition to downside risk, gradually increasing the maximum risk exposure as those ACOs gain more experience with the MSSP.

Most of the final regulation is consistent with the proposed rule. But certain key details were revised from the original proposal based on industry feedback and a refinement of CMS’s policy goals. The key changes are:

1. Increase to shared savings rate under the BASIC track.
2. Less strict definition of low-revenue ACO.
3. Current Track 1+ ACOs can enter BASIC track, Level E.
4. New, low-revenue ACOs can spend up to three years in an upside-only arrangement.
5. Removal of cap on risk score reductions to performance benchmarks (3% cap on risk score increases remains).
6. Slower schedule for regional cost adjustment reductions.
7. Prospective assignment for the July to December 2019 performance period.

Taken together, these changes from the proposed rule offer some opportunities to ACOs that may have been hesitant to enter or continue in the MSSP while maintaining a clear focus on fiscal responsibility and payment for value.

In this paper, Milliman’s Noah Champagne, Charlie Mills, and Jason Karcher discuss the changes to the MSSP financial benchmark and settlement parameters from the proposed rule in August and the final rule published in December.