Changes to the Medicare Shared Savings Program in the 2019 Medicare Physician Fee Schedule Proposed Rule

On July 12, the Centers for Medicare & Medicaid Services (CMS) published its 2019 Medicare Physician Fee Schedule Proposed Rule (Proposed Rule).  Weighing in at nearly 1,500 pages, the Proposed Rule covers a wide range of topics.  Over the next few weeks, we’ll summarize and offer our insights on several key provisions.  Comments on the Proposed Rule are due to CMS by September 10, 2018.  Expect CMS to publish the Final Rule around Thanksgiving.

Background on MSSP Quality Measures

The percentage of any shared savings an accountable care organization (ACO) participating in the Medicare Shared Savings Program (MSSP) receives is based on the ACO’s score on specified quality measures.  For the 2018 performance year, there are 31 measures across four categories:

  • Patient experience of care: 8 measures
  • Care coordination/patient safety: 10 measures
  • Preventive health: 8 measures
  • At-risk populations: 5 measures

Each category comprises 25% of an ACO’s overall quality score.  Because each category has a different number of measures, the measures in each category carry a different weight relative to the ACO’s overall quality score.  For example, if there are five measures in one category, each measure is worth 5% of the overall qualify score; if there are three measures in another category, each is worth 8.3%.

For some measures, an ACO receives full credit for compiling and reporting data to CMS, i.e., pay-for-reporting.  For others, an ACO receives full or partial credit based on its performance as compared to established benchmarks, i.e., pay-for-performance.

The data for the patient experience of care measures is collected through the Consumer Assessment of Healthcare Providers & Systems (CAHPS) for ACO Survey.  The data for the measures in the other three categories is either compiled by CMS from claims data, or reported by the ACO through the CMS Web Interface.

In addition to determining the percentage of shared savings, an ACO’s score on MSSP quality measures also impacts ACO participants’ Merit-Based Incentive Payment System (MIPS) score.  Specifically, an ACO’s score on the measures collected through the CMS Web Interface and the CAHPS for ACO Survey measures will determine ACO participants’ score on the quality component of the MIPS Alternative Payment Model (APM) Scoring Standard.  (More information regarding the MIPS APM Scoring Standard is available here.)

Proposed Revisions to MSSP Quality Measures

CAHPS for ACO Survey measures.  For 2019, CMS proposes including two additional CAHPS for ACO Survey measures to calculate an ACO’s score for the patient experience category: (1) courteous and helpful office staff; and (2) care coordination.  For 2019 and 2020, these two new measures would be pay-for-reporting, as required by the MSSP regulations.  Thus, as a practical matter, the inclusion of these two new measures means an ACO’s score on the pay-for-performance measures in this category will have less impact on the ACO’s overall quality score.

Claims-based measures.  Next, CMS proposes to retire three claims-based measures, which the agency believes have a high degree of overlap with other MSSP measures:

  • ACO-35: Skilled Nursing Facility (SNF) 30-Day All-Cause Readmission
  • ACO-36: All-Cause Unplanned Admissions for Patients with Diabetes
  • ACO-37: All-Cause Unplanned Admission for Patients with Heart Failure

CMS suggests it may include a different measure relating to SNF readmissions, but would do so through subsequent rulemaking (i.e., in 2020 or thereafter).

CMS also proposes retiring ACO-44: Use of Imaging Studies for Low Back Pain, noting the measure is restricted to individuals 18-50.  Although the measure is not directly relevant for most MSSP-attributed beneficiaries, CMS will continue to report an ACO’s score on this measure for informational purposes.

CMS Web Interface measures.  Consistent with the changes made to the CMS Web Interface measures under the Quality Payment Program, CMS proposes that ACOs no longer be responsible for reporting on the following measures beginning in performance year 2019:

  • ACO-12: Medication Reconciliation Post-Discharge
  • ACO-15: Pneumonia Vaccination Status for Older Adults
  • ACO-16: Body Mass Index Screening and Follow-Up
  • ACO-41: Diabetes: Eye Exam
  • ACO-30: Ischemic Vascular Disease:  Use of Aspirin or Another Antithrombotic

Presently, ACO-41 is one of two measures that comprise a composite diabetes measure, along with ACO-27:  Diabetes Poor A1C Control.  With the deletion of ACO-41, ACO-27 would be assessed as an individual measure.

Also, CMS proposes to replace ACO-13: Screening for Future Fall Risk, with ACO-47: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls.

In total, CMS is proposing to add 2 measures, eliminate 9 measures, and replace 1 measure, resulting in 24 measures for which ACOs would be held accountable.  Across the four categories, the number of measures would be as follows:

  • Patient experience of care: 10 measures (+2)
  • Care coordination/patient safety: 5 measures (-5)
  • Preventive health: 6 measures (-2)
  • At-risk populations: 3 measures (-1)

By proposing to streamline MSSP quality measures, CMS intends for ACOs to focus their performance improvement efforts on meaningful measures and to reduce the administrative burden associated with reporting through the CMS Web Interface.  Hopefully, CMS will revisit other aspects of the MSSP program (e.g., participation agreements, attribution, benchmarking) to overcome barriers to success.

PYA assists organizations in developing and operating ACOs, including performance improvement initiatives relating to MSSP quality measures.  For more information, contact one of our PYA executives below at (800) 270-9629.

© 2018 PYA

No portion of this article may be used or duplicated by any person or entity for any purpose without the express written permission of PYA.


David McMillan

David McMillan

Principal

Martie Ross

Martie Ross

Principal

Aaron Elias

Aaron Elias

Manager

Related Posts
The term “one size fits all” may be desirable in certain circumstances.  But, in many cases, the phrase more often translates to “just kind of fits.”  This is particularly true...
Read More

Finding the Right Fit: 4 Considerations When Choosing a Healthcare Auditor

PYA ranks on INSIDE Public Accounting’s list of Top 100 Accounting Firms for the third consecutive year.  PYA, a national accounting and management consulting firm, has been ranked as a...
Read More

PYA Again Among IPA’s Top 100 Largest Accounting Firms

Baltimore, Maryland, will be the host city for the American Health Lawyers Association 2018 Fraud and Compliance Forum.  The forum, which takes place September 26-28, offers fundamental, intermediate, and advanced...
Read More

PYA Supports AHLA Educational Efforts at 2018 Fraud and Compliance Forum

Becker’s Hospital Review recently published a synopsis, “Cardiologist shortage is coming: 5 things to know,” based on PYA’s latest infographic. The infographic shines a spotlight on the interrelated nature of...
Read More

PYA Infographic Featured in Becker’s Hospital Review

FVS Consulting Digest recently published an article, “The Opioid Crisis: The Important Role of CPAs,” co-authored by PYA Senior Manager Valerie Rock.  The article outlines the crucial role CPAs play...
Read More

The Opioid Crisis: The Important Role of CPAs

On July 12, the Centers for Medicare & Medicaid Services (CMS) published its 2019 Medicare Physician Fee Schedule Proposed Rule (Proposed Rule).  Weighing in at nearly 1,500 pages, the Proposed...
Read More

Changes to the Clinical Laboratory Fee Schedule in the 2019 Medicare Physician Fee Schedule Proposed Rule

On July 12, the Centers for Medicare & Medicaid Services (CMS) published its 2019 Medicare Physician Fee Schedule Proposed Rule (Proposed Rule).  Weighing in at nearly 1,500 pages, the Proposed...
Read More

Changes to Part B Drug Pricing in the 2019 Medicare Physician Fee Schedule Proposed Rule

On July 12, the Centers for Medicare & Medicaid Services (CMS) published its 2019 Medicare Physician Fee Schedule Proposed Rule (Proposed Rule).  Weighing in at nearly 1,500 pages, the Proposed...
Read More

2019 Medicare Physician Fee Schedule Proposed Rule

A recent article by PYA Consulting Manager Katie Culver has been published by Becker’s Hospital Review.  “Medicaid work requirements: What they mean for your healthcare organization,” explores state-imposed individual work...
Read More

Medicaid Work Requirements: What They Mean for your Healthcare Organization

Share This Insight

If you received value from this article, please share it with your network (e.g., Facebook, Twitter, LinkedIn). Icons below for your convenience.

Stay Current

PYA Population Health Ascend

PYA Healthcare Blog

PYA Thought Leadership Services

The Healthcare Loop