July 20, 2018

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) covering a wide range of topics.  In our series of articles, we have summarized and offered our insights on several key provisions.  Note that comments on the Proposed Rule were due to CMS by September 10, 2018, and we expect CMS to publish the Final Rule later this fall.   Of the 15,313 comments CMS received on the Proposed Rule, 1,212 of them included the acronym MIPS.  You can review all the comments here.

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.

About the Authors