John Malone
John Malone

The decision about whether to participate in the Centers for Medicare and Medicaid Services’ (CMS’s) new Medicare Shared Savings Program (MSSP), Pathways to Success, is complicated. It requires a detailed understanding of the rules of the program, your patient population, as well as your level of maturity with several key population-management capabilities (e.g., care management, analytics, and clinical redesign). These requirements raise a few questions and present challenges for current MSSP participants in upside-only arrangements and for new entrants considering joining the program. One of the most significant challenges is the requirement to take on downside risk much earlier in the program.

Joining Pathways to Success

On April 10, CMS announced updates to its Notice of Intent to Apply (NOIA) guidelines for the Jan. 1, 2020 MSSP agreement start date. The NOIA can be submitted between June 1 and June 28, 2019, with the final application due between July 1 and July 29, 2019. Therefore, provider entities considering joining Pathways to Success for the first time and current ACOs considering continuing in the program and taking on downside risk must quickly answer several important questions:

  • What can we do to forecast our potential financial outcomes (savings or losses)?
  • How can we prepare to obtain shared savings, and, if applicable, minimize our losses?
  • Overall, how can we prepare for success in the Pathways program?

Forecasting Outcomes

To effectively forecast future performance outcomes, new entrants must understand several key variables and MSSP program design elements. Chief among them are attribution methodologies and the ability to estimate beneficiary volumes to support forecasts of cost and quality performance. ACOs that are new to the program and with no previous experience managing risk will enter Pathways to Success in basic Level A. In addition to being upside only for two years, Level A beginners will have the option of choosing between retrospective and prospective attribution and can modify their choice at the beginning of each performance year.

Retrospective attribution may be better for ACOs with high beneficiary loyalty and advanced tools that allow tracking of patients who are receiving care in and out of the network. Advanced tracking allows for more accurate prediction of future attribution by CMS. Prospective attribution better supports ACOs that need more predictability and stability, which allows them to focus their resources on care management and cost reduction to earn shared savings. Either way, it’s important to develop an initial estimate of the number of attributed beneficiaries, because the number of estimated attributed beneficiaries is required to forecast various scenarios of cost and quality performance.

Getting Started

A good starting point to estimate attribution is to gather the number of unique Medicare beneficiaries (Part A and Part B only; Medicare Advantage is not eligible for assignment) and the number of primary care providers (PCPs) and specialists by group practice. A certain percentage of the patients seeing PCPs will be attributed, as well as a smaller percentage of the patients seeing specialists. The exact percentages depend on factors such as the level of competition in your market, your geography and proximity to other providers, and your historical leakage rate.

Depending on these factors, percentages can range between 40 to 80 percent of beneficiaries seen by your PCPs and a lesser percentage depending on your specialty (ranging from 5-20%+). CMS will provide retrospective totals of attributed beneficiaries for the previous three years as part of the MSSP application process, which allows for validation of initial forecasts.

Strategies for Success

Once enrolled, there are 7 strategies accountable care organizations (ACOs) can implement to significantly improve their probability of success in the new program:

  1. Reduce avoidable admissions, readmissions, and emergency department (ED) visits through care management
  2. Improve diagnosis coding to capture hierarchical condition category (HCC) codes
  3. Promote Annual Wellness Visits to patients
  4. Implement a post-acute strategy with strong alignment/preferred lists, and focus on poor utilization and quality
  5. Develop an ambulatory strategy to increase access (e.g., urgent care, outpatient testing, etc.)
  6. Develop care-intervention programs around chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and heart failure), and reduce clinical variation
  7. Implement an analytics framework to report and analyze the data around quality measures, cost data, and risk

The decision to participate in the new Pathways to Success program beginning in 2020 requires speedy and thorough information gathering and data analysis to forecast financial and quality outcomes. But that’s just the beginning: To be successful in the new program, ACOs must develop and extend new organizational and management capabilities. From care management to analytics and clinical redesign, these new capabilities are essential to success in the new program.

Subscribe to our Lumina Insights for future posts about the Pathways to Success program and how to achieve success.

John Malone is principal for Lumina Health Partners. Read Part 2 of this article series here.

Related Resources:

Subscribe to Our Insights