Tag Archives: ACOs

Overview of proposed Value in HealthCare Act

At the end of July, a bipartisan bill entitled “Value in HealthCare Act of 2020” was introduced to the U.S. House of Representatives, proposing a number of significant changes to the Centers for Medicare and Medicaid Services (CMS) Medicare Shared Savings Program (MSSP) and the Advanced Alternative Payment Model feature of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Given the timing of this bill, there is uncertainty about whether (or when) the bill will be passed into law. However, the introduction of it is a significant step toward encouraging value-based care and signifies an appetite for change in the MSSP in order to encourage additional participation of Accountable Care Organizations (ACOs).

In this paper, Milliman actuaries Noah Champagne and Andrew Yang discuss the proposed changes in this bill as well as the implications of each change on ACOs—in particular those under the Pathways to Success model.

Requirements for Qualifying Advanced APM Participant status increases

Accountable care organizations (ACOs) participating in Advanced Alternative Payment Models (Advanced APMs) are eligible to qualify for a payment bonus equal to 5% of Medicare Part B revenue and avoid Merit-based Incentive Payment System (MIPS) payment adjustments and reporting requirements.

For ACOs to receive the 5% bonus, they must achieve Qualifying Advanced APM Participant status (QP status) by meeting the eligibility criteria outlined by the Centers for Medicare and Medicaid Services (CMS). In 2021, the requirements for an ACO to achieve QP status will increase significantly over 2020 requirements, making it substantially harder for many ACOs to qualify.

In this paper, Milliman’s David Byron and Chris Smith explore 2021 QP status criteria and actions ACOs can take to ensure they continue to qualify for the 5% bonus, even during a pandemic.

How will the coronavirus affect Medicare Shared Savings Program ACOs?

The COVID-19 pandemic has created many uncertainties for providers and accountable care organizations (ACOs), which can seem overwhelming. Medicare Shared Savings Program (MSSP) ACOs are particularly concerned about the potential for 2020 results to decrease because of the virus. In this paper, Milliman actuaries discuss eight key considerations for MSSP and other risk-sharing arrangements as they assess the impact of COVID-19.

Comparing Direct Contracting to MSSP ACO and Next Generation ACO programs

Last year, the U.S. Department of Health and Human Services announced a new payment model called Direct Contracting for entities that want to take on risk for fee-for-service (FFS) Medicare beneficiary expenditures. This program built upon existing Centers for Medicare and Medicaid Services (CMS) efforts to reduce healthcare expenditures while attempting to improve the quality of care for FFS Medicare beneficiaries. Although Direct Contracting is designed to appeal to a wide range of entities (including those that have not previously participated in risk programs with CMS) many current Medicare Shared Savings Program (MSSP) and Next Generation accountable care organizations (ACOs) are naturally going to want to understand the potential pros and cons of this program, and how it compares to their current ACO risk-sharing structures.

In this paper, Milliman’s Colleen Norris, Brent Jensen, and Dustin Grzeskowiak provide an in-depth technical evaluation of Direct Contracting, based on the CMS request for applications, along with comparisons to its sister programs MSSP and Next Generation ACO.

Direct Contracting and MSSP financial benchmark comparison

In November 2019, the Centers for Medicare and Medicaid Services (CMS) released the request for applications (RFA) for the Direct Contracting (DC) model’s Professional and Global options. The RFA contains a significant amount of important information for program participants. This new payment model gives participating provider organizations two options for risk-sharing arrangements as well as the opportunity to receive a prospectively determined, more predictable revenue stream. Applications for the first program year are due to the Center for Medicare and Medicaid Innovation by May 1, 2020.

The DC payment model options are conceptually similar to the other CMS accountable care organization (ACO) options, the Medicare Shared Savings Program (MSSP), and the Next Generation ACO model. Participants take on risk and earn potential rewards based on the efficiency and quality of care for aligned beneficiaries.

This paper by Milliman’s Matt Kramer, Erica Reijula, and Sam Shellabarger compares and contrasts the financial benchmark methodology between DC and MSSP.

Calculating ACOs shared savings

In 2011, the Centers for Medicare and Medicaid Services (CMS) established the Medicare Shared Savings Program (MSSP) and brought the concept of the accountable care organization (ACO) to a wider audience. A key feature of the MSSP methodology is the minimum savings rate (MSR) and minimum loss rate (MLR). ACOs that participate in the MSSP are familiar with these corridors because they can mean the difference between receiving shared savings and receiving nothing. On the other hand, for ACOs currently taking downside risk, the MLR provides a buffer that neutralizes potential losses.

In this paper, Milliman’s Charlie Mills and Chris Smith explore the MSR/MLR options available to ACOs and provide perspective on what ACOs should consider when selecting the MSR/MLR under an MSSP track with a downside risk.