August 10, 2018
ACO Rule is Out
On August 9, 2018, CMS released a proposed rule describing a significant overhaul (called Pathways to Success) to their largest ACO program, the Medicare Shared Savings Program (MSSP). This proposed rule addresses two of the items that have produced tepid program-wide results so far: lack of ACOs taking on downside risk, and longevity within the program. Under this proposal, ACOs would have a limited time period in which they operate under an upside only model. For those ACOs opting for the lower risk (BASIC) track, transitioning away from an upside only track into a performance track that includes downside risk would occur during an expanded 5 year agreement period. ACOs could opt to accept downside risk from the start under an ENHANCED track. Additional track selection criteria will be applied based on the revenues and experience of the ACO, shifting larger and more experienced ACOs towards increased risk quicker than their smaller, newer counterparts.
Many of the specifics included in this proposed rule appear to build on the already favorable performance seen within the Next Generation ACO program, including a more straightforward risk adjustment methodology, expanded waivers to modify care delivery, and the ability for beneficiaries to voluntarily self-align to their provider of choice. Additional proposed modifications include: blended national and regional trends which account for an ACOs market share, annual selection of retrospective or prospective assignment, and expanded evaluation and management CPT codes used in assignment.
Wakely will be monitoring this proposed rule for additional changes before it is made final later this year. Contact Wakely’s provider risk experts at provider.risk@wakely.com to find out more information and discuss the potential implications for your organization.
A few additional news of note…
CBO Releases Medicaid Managed Care Report
CBO released a new report exploring the growth of Medicaid Managed Care. The report is full of information of enrollment and claims information that took over two years to compile. Give it read
MA Plans Allowed to Impose Step Therapy for Part B Drugs
CMS announced that Medicare Advantage plans could impose step therapy on certain Part B drugs. If they do, there are certain requirements from disclosures to opportunities for the beneficiary to participate in drug management care coordination activities. Step therapy for certain Part B drugs can only be imposed on new prescriptions in 2019. For more information please see the full announcement here.
Repeal and Release
Axios reported that if Republicans maintain control of the House and Senate, another try for repeal and replace should be expected in 2019.
Risk Adjustment
CMS released a proposed rule for the 2018 benefit year that would allow the original 2018 risk adjustment methodology be used in operations for the forthcoming risk adjustment cycle. This was in response to the recent legal ruling in New Mexico. When finalized in the fall, this would mean that there would be no interruptions or changes to risk adjustment as a result of the court case.