MSSP as a Chassis for Innovation: Digging Deeper on Four Potential Areas of Transformation

By Casey Korba, Director of Policy

At Aledade, we believe there is still opportunity for significant growth in accountable care organizations (ACOs). Last fall, we outlined in Health Affairs the case for using the Medicare Shared Savings Program (MSSP) as a “chassis” for innovation. The benefits of this chassis are fourfold: 

1. Significantly reduced level of effort compared to building a new, total cost of care model as all the contentious issues around benchmarking, risk adjustment, and governance are largely settled
2. Building on a track record of success in CMMI/CM collaboration with the Pioneer ACO Model, ACO Investment Model (AIM), and Track 1+
3. Access to the immediate scale of over 11 million beneficiaries in MSSP without forcing those ACOs to abandon MSSP in order to innovate with CMMI 
4. A ready-made comparison group of ACOs that did not elect the voluntary innovation model 

To further this idea, we developed a series of policy briefs describing in detail how this would work for four innovations: incorporating desired elements from the Next Generation ACO model, primary care capitation, value-based insurance design, and addressing inequity in health care. Below, we summarize and link to each brief.
 

Innovating Care Delivery with New Elements in Next Gen ACO Model 

• We present a new pathway for Next Gen participants by creating a new track within MSSP utilizing CMMI authority (or possibly using MSSP authority to test other payment models). The “Next Gen” Track within MSSP includes four elements: a discount instead of a shared savings rate; allowing ACOs to select the right providers; building a network; providing the Next Gen set payment waivers. 
• This new track would combine well-understood elements of Next Generation with the MSSP’s benchmark methodology that has demonstrated savings. Pegging the discount at 2% makes mathematical equivalency in savings to CMS at a 8% savings rate with Enhanced 75% share rate. Based on the evaluation of Next Gen it is likely that a 2% discount would have turned the program into a saver. 
   

Primary Care Capitation 

• In this article, we propose to bring together the primary care capitation component of ACO REACH (formerly Direct Contracting) with the scale of MSSP – empowering practices to succeed by doing what’s best for their patients. 
• The option to tear up the CPT codebook and invest in next-level population health interventions will push savings rates even higher and result in better care for beneficiaries. 
• The ACO community is hungry to innovate with primary care capitation, but most cannot risk resetting their benchmarks and adjusting to new risk adjustment rules. Including this model as an option within MSSP by January 1, 2023, can fuel both growth and innovation.
   

Value-Based Insurance Design (VBID)

• Here we make the case for CMMI to test a model for VBID that would allow physicians to waive cost-sharing for high-risk Medicare beneficiaries attributed to ACOs in MSSP when patients are receiving high-value, recommended primary care services. 
• MSSP is uniquely suited for VBID models – it already offers options to waive coinsurance in Part B. MSSP minimizes concerns about over or underutilization by not only holding participants accountable for cost but also requiring patient satisfaction surveys each year, and it wouldn't require new quality measures.
• Strengthening primary relationships in vulnerable populations is an important focus for Aledade that aligns with CMMI’s equity goals. The millions of Medicare beneficiaries without a primary care relationship are the hardest to reach and more likely to fall into care after an acute event that often could have been prevented with proactive primary care. 
• It could be game-changing for beneficiaries to simply allow an ACO to put a policy in place that all follow-up with hypertension is coinsurance free. 
   

Health Equity 

• We propose a feasible solution to drive more equitable and quality care to vulnerable patients through value-based bonus payments that reward physicians for establishing relationships with patients who need care most. Patients without primary care relationships should be identified and prioritized for establishing a medical relationship. 
• We recommend that for every new eligible patient a physician sees for an AWV, the physician is guaranteed a standard payment that will be either bonused or credited to their practice or clinic at the end of the calendar year or set as a PMPM payment. For every year the relationship is maintained, additional enablement funding should be awarded. 
• Our solution is rooted in simplicity and direct applicability. We recommend CMS identify patients as vulnerable and eligible for bonusing if they are located within a geographic or provider-based Health Professional Shortage Area. In the long term, we recommend vulnerability be directly associated with health needs SDoH screening assessments. This will require a large enough foundation of accurate data that has yet to be standardized, collected, and operationalized.