Tag Archives: Charlie Mills

What are the potential effects of prospective and retrospective assignment on key ACO metrics under the MSSP?

At the end of 2018, the Centers for Medicare and Medicaid Services published the Pathways to Success final rule for the Medicare Shared Savings Program (MSSP) giving accountable care organizations (ACOs) renewing July 1, 2019, or later the option to select between prospective and retrospective assignment of patients.

Under prospective assignment, beneficiaries are assigned to an ACO based on services occurring prior to the performance year. Under retrospective assignment, beneficiaries are assigned to an ACO based on services occurring during the performance year. Averages for assignment-eligible fee-for-service beneficiaries can help provide understanding of how the two assignment methodologies affect results.

Retrospective and prospective assignment have significantly different effects on the characteristics of the assigned populations for beneficiaries assigned to primary care physicians and specialists. Prospective and retrospective assignment will ultimately affect the population that is assigned to the ACO because some beneficiaries who are assigned under prospective assignment are not assigned under retrospective and vice versa. The choice between these assignment methodologies can have subtle effects on the ACO’s overall benchmark, risk score, and performance year costs.

In this brief, Milliman’s Sam Shellabarger, Charlie Mills, and Lance Anderson explore in more detail the potential effects of prospective and retrospective assignment on key ACO metrics under the MSSP.

“Pathways to Success” rule changes financial benchmark methodology

The Medicare Shared Savings Program (MSSP) final rule includes changes to the financial benchmark methodology that measures the gross savings or losses of an accountable care organization (ACO) under the MSSP. Four key elements of the financial benchmark methodology changed: agreement period length, regional fee-for-service (FFS) adjustment, risk adjustment, and trend.

In this paper, Milliman’s Jill Herbold, Cory Gusland, Charlie Mills, and Matt Kramer discuss these changes and important implications for Medicare ACOs. Each of these changes in the MSSP’s financial benchmark methodology will have significant implications for most ACOs. Given the increase in the agreement period length from three to five years, it is critical that ACOs assess how the final rule will affect their financial benchmarks and related strategies.





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.





Financial benchmark considerations for “Pathways to Success” MSSP proposed rule

The Centers for Medicare and Medicaid Services (CMS) proposed rule on the Medicare Shared Savings Program (MSSP) will significantly change the program if enacted. The proposal, titled “Pathways to Success,” includes changes to the financial benchmark methodology that measures gross savings or losses under the MSSP for an accountable care organization (ACO). There are four key elements where changes have been proposed: agreement period length, regional fee-for-service (FFS) adjustment, risk adjustment, and trend.

In this paper, consultants Jill HerboldCory Gusland, and Charlie Mills discuss the proposed changes and important implications for Medicare ACOs. This paper is the second in a series of Milliman papers on the proposed rule.





Considerations for proposed “Pathways to Success” regulation

On August 8, 2018, the Centers for Medicare and Medicaid Services (CMS) released a sweeping proposed regulation that, if enacted, will significantly change the Medicare Shared Savings Program (MSSP). The proposed regulation, titled “Pathways to Success,” accelerates the path for accountable care organizations (ACOs) to participate in shared risk arrangements while simultaneously softening key provisions, allowing lower revenue ACOs to participate with reduced total financial risk. In addition, CMS has proposed numerous methodological and operational changes.

In this paper, Milliman consultants provide a summary of the proposed regulation’s key provisions and briefly discuss how they might impact the MSSP.





Medicare Advantage’s transition from RAPS to EDS risk scores

In 2017, there were many changes to Medicare Advantage (MA) risk adjustment as the transition continued from Risk Adjustment Processing System (RAPS) data to Encounter Data System (EDS) data. MA organizations will also experience complexity and challenges in payment year (PY) 2019.

This article by Milliman’s Deana Bell, David Koenig, and Charlie Mills compares EDS and RAPS risk scores and details some of the program highlights from the past 12 months:

• A 25% EDS weight for PY 2017
• EDS file layout updates
• PY 2016 EDS deadline extension and change to payment timing
• PY 2017 RAPS and EDS deadline extensions
• Including inpatient RAPS diagnoses in EDS risk scores for PY 2019