New Rules for Some Medicare ACOs Are No Good, Say Healthcare Groups

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WASHINGTON — Groups representing doctors, hospitals, and accountable care organizations (ACOs) are pushing back on changes to quality reporting rules for Medicare Shared Savings Program (MSSP) ACOs that were finalized under the Trump administration.

“We have significant concerns about the MSSP quality policies finalized at the very end of 2020,” a group of 11 healthcare organizations, including the National Association of ACOs (NAACOS), the American Medical Association, and the American Hospital Association wrote in a seven-page letter sent to HHS Secretary Xavier Becerra at the end of April. “We believe there is an important opportunity for CMS to revise aspects of the recently finalized MSSP policies to better support ACOs and promote high-quality patient care.”

ACOs are groups of doctors, hospitals, and/or other healthcare providers that work together with a goal of providing better care at lower cost. The MSSP is a particular type of ACO in which participants can choose either “one-sided” risk — they can make additional money by meeting certain performance targets, but don’t lose money if they fail to meet the targets — or “two-sided” risk, which offers greater rewards but also financially penalizes plans if they fail to meet targets. There are currently 477 ACOs participating in the MSSP, and they provide care to approximately 10.7 million Medicare beneficiaries, according to CMS.

Among other issues, the letter singled out new quality measures developed by CMS known as Alternative Payment Model Performance Pathway (APP) measures. “The policy changes lacked adequate input from the patient, ACO, physician and hospital communities, and it is unclear how CMS determined that the APP measures are more appropriate than the current measures on which ACOs are evaluated,” the letter stated. “Quality measurement within the MSSP must focus on measures most appropriate to the program.”

The letter requested CMS to take several actions, including:

  • Delay the mandatory reporting of electronic clinical quality measures (eCQMs) and Merit-based Incentive Payment System CQMs for at least 3 years
  • Limit ACO reporting to ACO-assigned beneficiaries only, rather than all patients across payers
  • Reassess the appropriateness of the measures included in the APP measure set and solicit additional input from other stakeholders before finalizing a complete set of patient-centered measures for MSSP reporting

Allison Brennan, senior vice president of government affairs at NAACOS, expressed optimism about getting a response to the letter. “We’re hopeful that the new administration would take a really close look at the quality overhaul,” she said in a phone interview. “There were a lot of aspects of the regulation where CMS got feedback from stakeholders expressing concern and moved forward anyway … For that reason alone, we feel it should be revisited.”

In terms of the letter’s requests, Brennan said the 3-year delay was needed because of the difficulties inherent in collecting data from electronic health records (EHRs) as required under the new rules. She noted that a recent NAACOS survey found that 37% of ACOs used 15 or more EHRs across all of their participating providers’ offices. “Some of the fundamental problems we see, such as EHRs not being able to merge data seamlessly, those issues won’t be addressed or fixed in a year,” she said. “So it’s important to have a delay long enough to address some of these fundamental problems and to take a close look at the measures included in the measure set, and that process of collecting stakeholder feedback takes a longer time.”

NAACOS and the other signatories also expressed concern that the ACOs in the program would now be required to report quality metrics on all of their patients in each practice, regardless of whether or not they’re Medicare beneficiaries; until now they were only required to report on the Medicare patients assigned to the ACO. “So we’re exponentially increasing the reporting requirements for ACOs,” she said.

In addition, if all patients at a particular practice must be taken into account, that could end up penalizing practices who treat more vulnerable populations, Brennan said. “If you’re looking at two ACOs, and one is in Arlington, Virginia and treats a more affluent, commercially insured patient population along with Medicare patients, they may perform differently on quality than an ACO in an area where they have more Medicaid patients and are treating more vulnerable populations … I don’t think any methodological adjustment they’re doing is going to properly account for that.”

Fred Bentley, managing director at Avalere, a healthcare consulting firm in Washington, agreed. “I think NAACOS raises an interesting point,” he said in a phone interview. “Is it possible that ACOs end up looking worse, because of the reporting mechanisms and some of the challenges there?”

When contacted by MedPage Today, a CMS spokesperson said only that the agency “is reviewing the letter from the National Association of ACOs and other stakeholders regarding the quality reporting for the Medicare Shared Savings Program.”

Implementing some of the new requirements for ACOs is not surprising, said Lauren Cricchi, a consultant at Avalere. “The shift towards eCQMs has been happening for years and years, and all providers are held to those,” she said on the same phone interview with Bentley. “It is kind of the way that people are tending to move, and just sort of requires a little bit of forcing hands.”

Although the letter makes some good points, the new requirements “don’t fundamentally alter the ACO program or its relative attractiveness to new participants or existing participants,” Bentley said. “The world is moving towards types of electronic registries quickly becoming the standard of care, and it makes sense for ACOs to fall in line with the rest of the industry.”

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    Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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