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.
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.
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.