Preparing for changes to value-based care reimbursement in 2019 [podcast]

In August 2018, CMS unveiled its proposed “Pathways to Success” program – an overhaul of the existing Medicare Shared Savings Program (MSSP), which would redesign participation options for Accountable Care Organizations (ACOs).

It’s anticipated that the proposed program will pass in 2019. That means ACOs will need to prepare to transition from a multi-track reimbursement model to a two-track model, among other changes. Jake Aleckson, director of Optimization Solutions, and Steve Bloom, project director of Strategic Services, have been closely monitoring these proposed changes and how they will impact ACOs.

Jake and Steve discuss the changes ACOs can anticipate from the new MSSP in 2019, providing a breakdown of the consolidated tracks, reimbursement rates, and ways organizations can demonstrate value-based care. If you’d like to learn more or need help optimizing your value-based reimbursement program, please reach out.


Show notes

[00:00] Intros
[04:49] Overview of the landscape and CMS’ proposed changes to MSSP
[06:34] A breakdown of the new payment tracks
[10:20] A deep dive into “Pathways to Success”
[13:03] Key considerations for upside vs. downside risk
[17:05] Epic’s tools for HCC documentation and risk adjustment
[20:04] Industry feedback on these proposed changes
[20:52] Challenges for organizations that are not prepared for the changes
[22:10] Benefits for organizations that are prepared for the changes


Jake Aleckson: Steve, welcome to Nordic home office here in Madison, Wisconsin. Thanks for flying in this week for the Pop Health and Connect Summit that's in town at Epic. Looking forward to spending some time with you – so pulled this together here today to talk through some of the trends, the news that we're seeing from CMS that affects our value-based care landscape. Real quick, what I'm hoping to accomplish today, and then I'll let you introduce yourself, is where is CMS going right now? What are we hearing from them? Then what does that mean for organizations, navigating MIPS, advanced payment models, the routes that they're choosing and how are they preparing? Then we want to touch on our Epic support as well so how can Epic support these organizations population health goals. That's what I was hoping to cover today so I'm going to hand it over to you, let you introduce yourself.

Steve Bloom: Thanks, Jake. Yeah, very happy to be here in the home office. Just to give you a little bit of background on my viewpoint. I come from a health policy background. I worked in the U.S. Senate for a couple of years on value-based payment reform, in particular, worked in Washington on regulatory issues for several years before going back to grad school, getting my MBA and moving over to the consulting side. I've focused for the past five years or so now on really helping health systems to adapt to the changing landscape and help them understand what may be both on the horizon for them in the medium and long term and how they can best prepare for some of the changes that are happening in how health care is being paid for.

Jake: Awesome. Yeah, a unique background to Nordic. A lot of our consultants come from Epic or from other Epic organizations so it's great to have your point of view, your experience on board on the team. Real quick, my name is Jake Aleckson, director of optimization solutions here at Nordic. I've been in the Epic space for about 10 years now, consulting for about five. Majority of the time has been spent on Population Health-related projects, so our paths here have crossed at Nordic and we're looking to do some more work together so anything else to add, Steve?

Steve: Yeah, that's fantastic and what I've done for my time in consulting and really what is exciting about to me about being here at Nordic is I've worked for most of that five years with large Epic health systems, working hand-in-hand with the Epic technical experts to make sure that we are optimizing not only the strategy that the healthcare organizations are using, but allowing IT to enable and support that strategy. It's been great to be here at Nordic, kind of working hand in hand with the folks who have a lot more technical expertise in the Epic system than I do.

Jake: Yeah, great background though and I think it'll be good for this conversation today around what we're hearing from CMS around MSSP and that affect ACOs all across the country. Let's talk, lots of terms out there that I just threw out. Let's talk landscape and the basics just to start here before we dive into some of the details. Can you kind of just give us an overview of the landscape right now?

Steve: Yeah, so we titled this podcast, Value Based Care Trends and The New Medicare Shared Savings Program. There was a recent regulation released in August of this year, the comment period just closed in October so we're expecting a final regulation in December, January, that's going to outline a lot of key changes to the Medicare Shared Savings Plan, which is just one aspect of CMS’ strategy to move organizations in the direction of taking on more direct responsibility for the health of their patients. In the world of CMS, that means a lot of times going at risk for the cost and quality of care that you're delivering to patients. And so, in order to maximize your approach in those areas, it's really about a couple of different strategies; looking at making sure that you are performing the kinds of preventative care outreach that are going to impact patient health and then properly documenting for those as well. We'll talk about that today.

Jake: Yeah, so organizations, innovative ways that they're providing care out there that can then affect greatly that reimbursement. Do we want to touch on the two tracks that are currently out there?

Steve: Sure, so just to take a quick step back in the Medicare Shared Savings Program is one avenue that many health systems are pursuing to meet CMS' requirements that folks participate in some form of quality program risk sharing for their participants. Folks can either choose to proactively join something like a shared savings program or they can kind of default into what's known as the MIPS track, where CMS will automatically either add to or deduct from your physician fee schedule payments based on the quality and cost and meaningful use of technology that you are tackling at your organization. Within MSSP, organizations have a couple of choices to your point. Currently, the track options are numbered, one, one plus, two, three, along with a couple of advanced options like the next gen ACO program. CMS is moving in the direction of consolidating some of these tracks, so they are proposing to change to push organizations either to a basic track or an enhanced track. Essentially, the basic track incorporates track one and one plus. The enhanced track is track three with a few key changes to the program that we'll talk about today.

Jake: These tracks they can lead to upside and downside risk for these organizations. Where are majority of organizations right now as far as taking on some of that upside and that downside risk?

Steve BloomSteve: Yeah, so 82 percent of organizations right now are taking on only upside risk, which means they're in either the track one or track one plus MSSP program. CMS is really trying to push for folks into downside risk. They have cited that MSSP program right now is actually costing Medicare money and they want to move in the direction of the intention of the program, which is actually pushing for those savings for Medicare.

Jake: One thing kind of back to the landscape that I think people ask is with our political situation out there and the midterm elections that just happened yesterday, how are the changes in Washington affecting CMS and this program specifically?

Steve: Yeah, so unlike many aspects of health reform, the payment adjustments and payment reform that started or was accelerated as part of health reform has been bipartisan and the new administration, while taking a couple of digs at the prior administration for not saving enough money through the program is really continuing and accelerating the push for payment reform.

Jake: I think that's interesting. I think a lot of people ask that question. You started to dive into some of those changes around the tracks and CMS just proposed a new, I think they're calling it the “Pathways to Success.” Let's dive into that a little bit. What are some of the differences or changes? I don't think it's been finalized yet, but what are we seeing out there and then how can organizations start to prepare?

Steve: Yeah, so that's a really good point, this is a proposal subject to finalization, but some of the key aspects of the new MSSP program that CMS is proposing are, we mentioned the consolidation of the tracks, but they are also extending the agreement period. Right now, organizations are signing three-year agreement periods. This would move them to five-year and six-month contracts over which time your benchmark would be set for the full time period and it really locks in some of the key metrics that organizations would want to be targeting for their patients so it allows you to kind of have some more consistency in your expectations for what targets you're supposed to be hitting.

Steve: There's also additional flexibility in terms of beneficiary targeting the types of services you can offer to beneficiaries, so participants would actually have the option of electing prospective beneficiary assignment or prospective with retrospective assignment. What that means is, you could get a list of patients that you're targeting right at the outset of your performance here and so that really enables some exciting new ways that you could leverage data and your EHR system to target particular groups of patients with the interventions that are going to help save money and improve quality.

Jake: I think that brings up a good point and it ties back to a prior podcast that we did around MSSP submission, where one of the last steps come the following years received that file from CMS of the patients that they're going to be looking at. What you're saying is that one of the changes or proposed changes would be to receive that at the beginning of the year to them be able to act on those patients proactively throughout the year.

Steve: Yeah, absolutely.

Jake: So we talked about the contract length as well, the benchmarking, what about I think you had said a majority of organizations right now are pretty much just upside risk. How is CMS starting to push organizations to more of that downside risk?

Steve: Yeah, so essentially, under the current rules, organizations could have up to six years in upside only contracts. These rules are pushing organizations to a maximum of two-and-a-half years. If you are an organization that has participated in an MSSP and you're up for a new contract year, you will get two-and-a-half more years of potential upside only and so that means you would not need to pay back CMS if you ended up with losses resulting from the program versus your benchmark, but what's new is, I mentioned that the agreement period is five and a half years, whereas previously, you were sort of fixed in how much risk you would be taking on over the course of your agreement period, over those three years. Under the new arrangement, each year of your five-year performance period, you would be advancing in a step on your journey to take on downside risk.

Steve: Under what's called the basic track, which is designed for those organizations who were previously considering a track one or a track one plus, you would again have upside only for the first two-and-a-half years and by the end of your period, by the end of that five year period, you would be eligible for 50 percent upside shared savings and 30 percent downside shared savings so again, pushing folks to risk more quickly. Now, I will say that the downside is capped at whatever the current MIPS penalty is. So you won't be losing out any more than you would if you chose the MIPS track.

Steve: One of the final interesting aspects of the changes proposed fall into the category of risk adjustment so when organizations are asked to show savings against a particular benchmark, risk adjustment is the system that's used to determine whether an organization's patients are sicker or healthier than the general population and that can impact how much savings you have to show. Right, because obviously, it is more expensive to care for patients that are more complex. The previous proposal did not allow for any increase in the complexity of your patient population over the course of your benchmark period so you were sort of fixed at a certain level of patient acuity. You could go down. So if your patients got healthier, CMS would grab back that credit but you couldn't show that your patients were getting sicker over time.

Steve: The new proposal allows your risk scores to go up by 3 percent over the performance period. So if either there's a change in how sick your patients are, or you're improving the chronic condition documentation and billing at your organization, you can sort of get a little additional boost and demonstrate to CMS that you should be entitled to greater savings against a sicker patient population.

Jake: I think that's a really good point, Steve. I know we wanted to touch on this in a little bit around some of the Epic tools that can help support some of these initiatives and I think this is a good time to interject on the risk adjustment, which would be the tools around HCC. I know Epic does have some excellent basic tools around registries and best practice advisories to notify those clinicians that, hey, this patient has had diagnosis in the past, think about documenting and to discussing these with the patient to then increase that patient's HCC score. I know Nordic's doing work with multiple organizations now around HCC and do we want to kind of touch on some of the details around that?

Steve: Sure. Yeah, when it comes to risk adjustment and HCC documentation, the name of the game is making sure that you are accurately accounting for all the chronic conditions that your patients face on a daily basis and when you're improving that chronic condition documentation, it has multiple benefits across the organization. It can aid in improving your patient outreach strategy, improving your point of care support for making your patients part of a patient-centered medical home, making them feel as if you are actively caring for all of the conditions they face on a daily basis. And it helps to demonstrate to CMS through multiple programs that you are caring for a more complex patient population and should receive a greater share of care funding to compensate for that, so HCC becomes very important as CMS moves towards pushing organizations into risk.

Jake: Definitely sounds like an opportunity for organizations to improve the tools within the system and the education to providers and staff around HCC to then take advantage of some of these changes that are possibly coming.

Steve: Yeah, some of the strategies we've seen organizations successfully use are, you mentioned some of the point-of-care documentation, support, targeting patients that have or suspected conditions and getting them in for visits to have those conditions evaluated and added to problem list and billings. Epic's Healthy Planet tool is a very flexible program that allows for a lot of build-out to support documentation and in key areas for both risk adjustment and actually the quality side as well so some of those quality scores that CMS is using to judge performance as well.

Jake-AlecksonJake: Yeah, good point. Let's jump back to some of those changes to the program. What are we hearing industry wise, some feedback from organizations about these changes that are possibly coming?

Steve: Yeah, so there's been sort of mixed reviews on the new proposal. Many of the ACO organizations and provider organizations out there don't like the fact that CMS has decreased the upside potential on shared savings. One of the changes that I don't think we fully touched on was, if you are in an upside risk arrangement, the maximum savings that you could achieve is going to fall from 50 percent to 25 percent. So that could really impact on folks' decision making as they're thinking through whether an MSSP makes sense as well.

Jake: Then what are some of the implications if organizations are not ready for some of these changes?

Steve: Yeah, so again, CMS is pushing folks into risk and accountability for their patients, whether they are proactively choosing to participate in CMS programs or not. So if you choose not to pursue some of these what are called advance payment models like MSSP bundled payment program, etc., you are automatically eligible for what's known as the MIPS program, which will either penalize or reward organizations by plus or minus 4 percent of their fee schedule payments in 2019, up to 9 percent in the coming years. There are some additional benefits if you choose to participate in advance payment models and sort of take these proactive steps now. In addition to sort of orienting your culture and organization to better proactively outreach to patients and document effectively for these programs, there's also a 5 percent bonus that organizations will receive if a certain percentage of their patients are participating or if a certain percentage of revenue is coming from advance payment models. CMS is really pushing folks to innovate to take on some of these advanced programs and the payment incentives to do so can be quite significant depending on your organizational circumstance.

Jake: It's definitely not a downside to be going down the MIPS track, but it sounds like if organizations are prepared and are on top of this, the upside is much greater.

Steve: Yeah, it really depends on circumstance, what advance payment model is going to make sense for your organization and in some cases, it would make sense for folks to pursue the MIPS track, but the key here is that health systems really need to be thinking about an organizational strategy to make a proactive choice, right. Evaluate your options and move in one direction or another and most importantly, make sure that you're prepared from an organizational culture standpoint, a documentation standpoint to be showing your pairs the steps that you're taking to proactively manage population health.

Jake: Yep, and improve patient care. Yeah, I think Steve, I mean this was a good discussion. I think people will find value in listening to this, hearing about what's coming with MSSP, what Epic tools are out there to support their population health journey so appreciate you taking the time today to talk and talking through this with us.

Steve: Thanks, Jake. I'm happy to be here.

Topics: Performance Improvement

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