The Medicare Shared Savings Program (MSSP) had arguably the biggest overhaul in its existence this past December raising many eyebrows across the landscape. Although most of you (over 90% in 2017) are in MIPS, the Merit-based Incentive Payment System, there are growing numbers of clinicians in one of the Medicare Shared Savings Program tracks. Of these, most are in the track (MSSP-1) that is upside only- in other words the model in which there is no downside risk of owing money to CMS if the ACO underperforms relative to a benchmark. The advantages of being placed in MIPS-APM and the lack of downside risk were some of the reasons networks and physicians opted into MSSP-1.
However, with the redesign of the Medicare Shared Savings Program that was proposed early in 2018 and finalized towards the end of the year as the “Pathways to Success”, physicians and networks must seriously reconsider re-enrolling in this program. Seema Verma, the current Administrator for CMS made it clear that her objective was to more aggressively move physicians into risk-based models. According to CMS, data demonstrated that groups in the risk-based models outperformed those that were upside only. To that end, CMS confirmed a revamp of the MSSP program which essentially forces all ACOs to progress towards a risk-based model. Tracks 1,2, and 3 are now gone and replaced by the BASIC and ENHANCED tracks, both of which involve risk of some type and which are now five-year contracts (up from three). Depending on the experience of the organization, those opting into the BASIC track may qualify for up to 3 years of an upside-only model (A, B, and possibly C), but will incur downside risk in at least the last two years (D and E). The ENCHANCED track (essentially equivalent to the former Track e model) incurs the highest degree of risk, though also allows the highest level of possible shared savings.
What are the implications?
The calculation of shared losses is dependent on the revenue of the participants within an ACO. Because of this, ACOs that include both primary care doctors and specialists should reconsider participation in the MSSP program now that risk is mandated. Since the loss sharing limit is calculated as a portion of revenues of ACO participants, it makes sense to exclude as much revenue as possible. As specialists contribute to less of the quality metrics in an MSSP compared to primary care doctors, they may be considered less vital in the determination of shared savings compared to their colleagues in primary care. Therefore, excluding specialists in an ACO is an attractive option as it retains only those participants that most directly impact shared savings (the primary care doctors) yet reduces the exposure to risk by excluding much revenue as possible (the specialists). In effect, this further increases the focus on primary care clinicians in generating additional revenue for a group. As an alternative pathway to excluding specialists from their ACO, some multispecialty groups may choose to exit the MSSP altogether.
Another factor that might further push organizations to reconsider participation in MSSP is the concept of low and high revenue ACOs. The low revenue designation is meant to encourage participation of physician-led ACOs and rural hospitals by allowing for a more gradual transition to risk-based models, however in so doing, many hospitals will be categorized as a high revenue ACO and be forced into the highest risk models much sooner. Further compounding the issue for organizations is that CMS will make the determination if an organization will be considered low or high revenue. This results in some loss of control for organizations in terms of deciding how much risk they are willing to take, since being designated a high revenue forces participation in the models with more risk.
The net effect of all these factors may result in increasing numbers of organizations deciding to opt-out of MSSP and either returning to or staying in MIPS. CMS must be betting that mass exodus out of MSSP is a less likely scenario, since the consequences of the unravelling of the ACO model would have disastrous consequences given the enormous investment in time, energy, and money that has gone into its development and promotion.
Where does this leave the neuroradiologist? If organizations choose to enter into an MSSP agreement with only primary care doctors, this only further increases the perception of primary care doctors driving quality measures as opposed to specialists such as radiologists. If radiologists are formally excluded from an ACO, we must work even harder to prove to an organization that value in radiology is paramount not only in increasing quality care for our patients but also in potentially decreasing costs. For example, by implementing clinical decision support, an organization could potentially reduce utilization and decrease a network’s costs. An argument could even be made to the organization that these savings be shared with the radiology department.
MSSP metrics have always been tilted towards primary care measures and the redesign of the program only confirms this framework. It is critical for us as neuroradiologists that we demonstrate to the healthcare community our commitment to quality. In fact, regardless of whether radiologists are part of an organization that is participating in this new brand of MSSP or not, it is still in our best interests to actively demonstrate quality. There are many metrics that are available for us to measure the quality of the care we provide our patients. Many of these are available as convenient registries that the ACR offers (DIR, GRID, NMD, and R-SCAN among many others). Now more than ever, radiologists must actively demonstrate quality to an organization to prove its value.