Executive Summary: NBCH Comments on the Medicare Shared Savings Program (MSSP) and Accountable Care Organizations (ACOs)
Patient Protection and Affordable Care Act of 2010 (PPACA)
Executive Summary: NBCH Comments on the Medicare Shared Savings Program (MSSP) and Accountable Care Organizations (ACOs)
NBCH supports the core concepts of the ACO program to achieve better care for patients, better health for communities and appropriate containment of Medicare costs. Our member business coalitions represent large self-insured employers and unions all across the country so we also understand the real opportunity for change that the MSSP program represents and we want to ensure that it successfully transitions to the private sector.
General NBCH Perspective on Proposed Rule Provisions:
NBCH supports the concept of ACOs as envisioned in the PPACA legislation. ACOs have the potential to transform health care to a better organized, integrated, patient-centered, prevention and outcome-oriented delivery system. To meet its full potential and promise, however, certain principles and requirements will need to be included in the final regulation.We also support the following concepts:
- NBCH believes that ACOs should be accountable for maintaining the health of a defined population and achieving performance results aligned with the “triple aim” goals of improving risk- adjusted population health, improving quality of care and lowering costs without cost-shifting to the broader private sector.
- Ensure that there is an alignment between the proposed rule and those seeking to use medical homes within an ACO structure. This would mean that CMS should allow the basic operational components of medical homes or certifications from appropriate organizations to guide and satisfy basic quality standards in the area of delivery of primary care services.
- Require that ACOs are built on a foundation of primary care practices oriented towards prevention, chronic care management and coordinated, patient-centered care. Further, CMS should consider models that are led only by primary care practices.
- Create consumer incentives and other strategies so that individuals will be motivated to select primary care practices participating in ACOs and, if possible, motivated to align their behavior and treatment choices and with the goals of better health and cost-effective care.
- Require or provide significant incentives for all-payer ACOs that will assure practice-wide transformation and that will avoid aggravating the current spiral of cost-shifting to the private sector to make up for “Medicare losses”.
- Require that ACOs are flexible and able to work with the needs of the consumers and providers in their community by supporting strong provider payment reform models beyond shared savings approaches and in the direction of rewards reaching triple aim goals.
- Refine the current anti-trust provisions in health care in a manner that, on the one hand, enables collaboration and alignment that strengthens the drivers of triple aim goals, but, on the other hand, guards against the current pattern of consolidation and market dominance that has contributed to our nation’s unsustainable health care costs.
NBCH’s Specific Comments on Proposed Rule Provisions:
Governance: Create fair & balanced representation.
NBCH encourages HHS to support an ACO governance structure that avoids market domination by any one group. In the proposed rule, CMS asked about the appropriateness of ACO participants having at least 75 percent control of the organization’s governing structure. We suggest that CMS require a more balanced composition, with perhaps 50 percent ACO participant representation, a majority of which should be primary care providers, and 50 percent key community stakeholders. And, the inclusion of an employer and/or labor representatives also serves as a way to help prevent cost-shifting to the private sector, which is a major concern for NBCH and our member coalitions.
Eligible Entities: Support small practice participation & all-payer ACOs.
NBCH is pleased that HHS recognizes the importance for ACOs to be built on a foundation of primary care practices (general practice, internal medicine, family practice, and geriatric medicine) which are oriented towards prevention, chronic care management and coordinated, patient-centered care. We are pleased that groups of small, independent practices of ACO professionals, including nurse practitioners are being given the opportunity to form or participate in ACOs. However, we are concerned about the specifications in PPACA regarding entities that would be eligible to form an ACO and participate in the program, particularly language allowing strong hospital leadership. Given past experience and hard lessons learned by our geographically diverse coalition membership, strong hospital dominance in some communities can exacerbate consolidation in local markets and artificially inflate health care prices as well as shift costs to the private sector. For that same reason, NBCH supports incentives for all-payer ACOs that will assure practice-wide transformation and that will avoid aggravating the current spiral of cost shifting to the private sector to make up for “Medicare losses”.
Sufficient Number of Primary Care Providers and Beneficiaries: TIN is an appropriate indicator.
NBCH supports the proposed method for determining if the threshold of 5,000 beneficiaries is met by using the ACO participants TIN’s number as well as the threshold proposed for participants to remain eligible for MSSP.
Required Reporting on Participating ACO Professionals: Transparency on quality and costs.
NBCH supports HHS’ requirement that entities applying to participate in the shared savings program must provide TINs (Tax Identification Numbers) of the ACO and the ACO participants, as well as a list of national provider identifiers (NPIs) associated with ACO providers/suppliers. We also support the provider transparency requirement in which an ACO would be required to maintain, update, and annually report to CMS the TINs of its ACO participants and the NPIs associated with the ACO providers/suppliers. This requirement is important for having provider-level transparency on quality and costs.Ultimately, ACO involvement of regional collaborative could be an effective means to align initiatives and to pool data enabling, for example, performance reporting at the physician level.
Processes to Promote Evidence-Based Medicine, Patient-Engagement, and Reporting: Provide specific tools & incentives to encourage patient involvement.
NBCH strongly supports requiring ACOs to promote evidence-based medicine, patient engagement, reporting on cost and quality, and coordination of care. The combination of these practices is extremely important to achieving a more effective, efficient, and patient-centered health care system.We agree with the assertion that at this point in the process it is difficult to identify the best way to promote these practices, thus making it difficult to be prescriptive. However, we feel the current requirements should be strengthened by: 1) requiring sufficient level of detail on processes and tools that will be utilized, 2) requiring ACOs to monitor the level of success in these practices and make adjustments as necessary, 3) including measures that assess the intended outcomes of these practices in the quality reporting requirement, and4) holding ACO accountable for adhering to their stated place.
Patient-Centeredness Criteria: Criteria are strong; more detail needed on monitoring & enforcement.
NBCH appreciates and supports all eight criteria HHS proposes for an ACO to meet to be considered patient-centered. These criteria are essential to the transformation of a better health care delivery system.
We urge CMS to specify how it will monitor and enforce the requirements that ACO develop and adhere to these patient-centered criteria. We also recommend a very high bar/score for patient-centered measures with accommodations for lower “entry” status for some ACOs. However, all ACOs should be required to show progress toward the higher threshold of capabilities.
Program Integrity and Requirements-Prohibition on Certain Required Referrals and Cost Shifting: A more robust system is needed.
NBCH understands that ACOs will require infrastructure changes that will affect, and hopefully benefit their entire patient population served– including Medicare, Medicaid, or commercially insured patients. There should be a system for ongoing monitoring the potential consequences of increased market power (i.e., increased prices for the private sector and cost-shifting). Per the Shared Savings proposed rule, NBCH supports CMS conducting data analyses to look at patterns in the use of health care services inside and outside ACOs. CMS needs to add requirements to the ACO program to build a more robust monitoring system. In particular, CMS could require all participating ACOs to have a mechanism in place for assessing performance on private sector per capita costs by the second year of the program.
Assignment of Medicare Fee-for-Service Beneficiaries: Give ACOs & beneficiaries advance notice.
The rule proposes that Medicare beneficiaries be assigned to an ACO if they receive plurality of primary care services from a primary care doctor in the ACO, based on allowed charges. Alignment is retroactive for the purposes of determining shared savings, but an ACO will know prospectively which beneficiaries will be receiving care from physicians in the ACO, which we support. This acknowledges the importance of informing patients about their participation in an ACO. NBCH believes it would be helpful for CMS to provide ACOs with timely information on eligible patients in the ACO, particularly to help support care management of the population.
Prospective v. Retrospective Beneficiary Assignment to Calculate Eligibility for Shared Savings: A different attribution approach needed to include other primary care providers.
NBCH believes that ACOs should be accountable for a defined population. Therefore we favor prior consumer selection of a primary care physician affiliated with an ACO. We applaud HHS’ efforts to launch a public campaign to educate beneficiaries about the benefits and advantages of ACO participation. We further recommend that CMS consider the use of financial incentives (e.g. Part B lower premium share) for ACO selection. Specialist and hospital attribution is relevant for performance evaluation purposes and primary care referral decisions, but should not be part of the shared savings model. The ACO should be able to determine attribution for the bulk of specialist and hospital transactions, through arrangements such as “prior notification” with specialists and hospitals.
Proposed Measures to Assess the Quality of Care Furnished by an ACO: Measures should demonstrate value & relevance.
NBCH supports the idea of using measures to assess the quality of care provided by participating Medicare ACOs, but is concerned about the relevance and value of some the measures, and believes that a more gradual measurement approach, which evolves as better measures become. ACOs are required to report on 65 measures the first year of the new Shared Savings program in five domains: patient experience; care coordination; patient safety; preventive health; and at‐risk population. ACOs that do not meet quality standards are not eligible for shared savings.
NBCH supports CMS’ effort to define measures for ACOs across the delivery system. We think it is essential for the program to have a strong quality accountability component, particularly in the context of a program that engages providers in seeking savings in overall resource use. However, of the 65 proposed measures, 50+ impose a significant data collection burden. We believe that it is possible to establish an extremely high set of quality standards using measures that impose less of a data collection burden on fledgling ACOs and are of high value to consumers and their providers.
Processes to Report on Quality and Cost Measures: Strengthen access and standardization of all-payer claims data.
NBCH also supports the use of standardized metrics to assess patient experience, quality, costs, outcomes and efficiency. We suggest that measures be aligned with existing measures being used by other organizations and reporting programs. We recognize that there is a lack of nationally accepted measures of cost and resource use, so we hope that the ACO program may identify measures that could be adopted for national use.
NBCH firmly believes that strengthening access and standardization of all-payer claims data is essential to national public reporting as well as the burgeoning payment reform initiatives. NBCH and our coalition members need support for legislation and administrative actions to help make all-payer data as accessible and uniform as possible from state to state. We ask that HHS take the lead in setting standards and requiring uniformity at a national level.
Public Reporting: Individual provider-level data is needed.
NBCH believes that the amount of transparency on quality performance is minimal and problematic, especially if reporting is only at the ACO-level. It is not sufficient for measurement and reporting to take place at the ACO level only. Research has shown that much of the variation occurs at the individual physician level, not the practice site or group level. Knowing how an ACO scores on average is not sufficient to guide incentive programs that can motivate individual physicians.Also, for a program to be truly patient-centered, it must give consumers information at the individual provider level. CMS must require both provider-level and ACO-level reporting.
Monitoring avoidance of at risk beneficiaries: Monitoring intentional patient risk selection is important.
In the proposed rule, CMS is required to analyze claims and other beneficiary-level documents to identify trends and patterns suggestive of avoidance of at-risk beneficiaries. This is an important element considering that the primary goal of MSSP is for ACOs to coordinate care for the sickest beneficiaries to improve their health outcomes while improving cost efficiency. Unfortunately, there is somewhat of an innate program contradiction since what makes the MMSP attractive also creates the potential of incentivizing ACOs to avoid the sicker and costlier patients. NBCH supports CMS efforts to monitor ACOs for signs of intentional avoidance of high-risk patients as well as the plan to impose corrective action on an ACO found in violation of this principle. We also support termination of ACOs who are found to be engaging in patient selection.
Antitrust Enforcement Policy Regarding ACOs: NBCH Supports the ACO 40 Percent Threshold Review.
It is vitally important to refine the current anti-trust provisions in health care in a manner that, on the one hand, enables collaboration and alignment that strengthens the drivers of triple aim goals, but, on the other hand, guards against the current pattern of consolidation and market dominance that has fueled high costs in this country. NBCH strongly recommends that the federal government monitor per capita costs and CMS require that ACOs include community representatives, especially consumers and purchasers, on its governing board.Another important way to help address the risk of inappropriate cost-shifting within Medicare and other Federal health care programs, NBCH also supports prohibiting ACOs and their ACO participants from conditioning participation in the ACO on referrals of Federal health care program business that the ACO or its ACO participants know or should know is being provided to beneficiaries who are not assigned to the ACO. However, we are concerned about CMS’ proposal to require ACOs that exceed the 50 percent threshold to undergo a mandatory antitrust review.We believe a 40 percent threshold would be an effective way to ensure that there are sufficient providers to allow the formation of competing ACOs to serve Medicare beneficiaries.
(For the complete extended version of NBCH's Comments to CMS: click here)