Full-Risk Option Needed in the Shared Savings Program

July 20, 2023
“Enhanced Plus” would provide a better bridge from MSSP to ACO REACH

  • ACOs would benefit from a permanent, full-risk option in MSSP to complement what’s available in ACO REACH as interest in two-sided risk ACOs has grown and two-thirds of MSSP ACOs are now at risk.
  • Enhanced Plus would use MSSP as an innovation platform, embedding successful elements and lessons learned from CMS Innovation Center models.
  • CMS sought request for comment on creating a full-risk track within MSSP in the recently proposed Medicare Physician Fee Schedule.

By: David Pittman, Director, Communications and Regulatory Affairs, National Association of ACOs 

Accountable care organizations (ACOs) have more options than ever to participate in Medicare total cost of care models. The Medicare Shared Savings Program (MSSP) now offers six tracks – after starting in 2012 with two. All run the gamut of risk and reward and programmatic flexibilities, yet there is not a full risk option.  

The National Association of ACOs (NAACOS) has been advocating for the Centers for Medicare and Medicaid Services (CMS) to offer a full-risk track within MSSP that would provide a better bridge to ACO REACH and offer more flexibility and options for capitation to those willing to innovate. The highest risk option available in MSSP today allows ACOs to share in 75 percent of shared savings or losses. 

NAACOS has coined this full-risk option “Enhanced Plus,” which references both the current Enhanced track of MSSP and the now retired Track 1+ option. A similar option is needed between the Enhanced Track, which offers a 75 percent shared savings rate, and a full-risk option, which is only available under the Global option of ACO REACH

Elements NAACOS has suggested for inclusion in Enhanced Plus include:

  • 100 percent shared savings and loss rates;
  • Participation at the individual level, rather than hospital or practice level;
  • Options for population-based (e.g., capitated) payments, ranging from partial to full capitation with the ability to negotiate value-based payment arrangements with downstream providers;
  • Apply a regional-only benchmarking trend to best reflect local market changes; and
  • Offer advanced waivers, including post discharge home visit waiver, care management home visit waiver, tailored Part B cost sharing support. ACOs should have maximum flexibility to determine how to implement the benefit.

To date, a full-risk track has only been available in CMS Innovation Center models, of which MSSP is not one. But there is evidence that ACOs are more willing to take on risk when they feel ready. In 2023, two-thirds of MSSP ACOs are under financial risk. MSSP’s most popular track is Enhanced, which boasts more than a third of all MSSP ACOs. But the CMS Innovation Center is not allowing another application cycle for ACO REACH, giving those interested in higher levels of risk no opportunity for a full-risk option. 

Enhanced Plus could imbed some elements only available in Innovation Center models into MSSP, allowing more ACOs to innovate themselves and deliver higher quality patient care. In ACO REACH, providers are allowed to make home visits more easily to patients after their discharge from a hospital, provide home visits for chronic care management to help with high-needs patients, offer cost sharing support, among other waivers. All waivers are not allowed in traditional Medicare, which is a benefit to participating in a full-risk ACO. 

CMS seems open to our idea. In last week’s proposed Medicare Physician Fee Schedule rule, the agency included a request for comment on a higher risk track within MSSP. CMS notes that only highly confident ACOs, who have proven their success, may be interested in this Enhanced Plus option, which may lead to more shared savings payments to ACOs and less savings for CMS to keep. As such, the agency may need to rethink the financial protections it offers other ACOs, such as a cap on shared savings and losses and truncating expenditures for the costliest 1 percent of patients. The agency is also worried that ACOs may avoid high-cost patients, and therefore the agency wants ideas on how to prevent that. But it’s a positive sign that CMS is seeking comment on our calls and thinking harder about expanding the menu of options for ACOs as it works to reach its goal of having all Medicare beneficiaries in an accountable care relationship by 2030. 

There is still work to be done and questions remain unanswered. For starters, CMS is only requesting stakeholder feedback on an Enhanced Plus option and hasn’t proposed any change to MSSP. But overall, creating an Enhanced Plus track would better use MSSP as an innovation platform, embedding successful elements and lessons learned from CMS Innovation Center models to be permanently embedded within Medicare.