MSSP Season Is Here! Should You Participate, and if You Participate, Are You Prepared for Downside Risk?

Understanding the timeline: application process starts June 1, 2022

Medicare Shared Savings Program (MSSP) is Medicare’s established accountable care organization (ACO) program that allows for new participants every performance year (PY). To participate in MSSP, an organization must submit an application and be approved by CMS. For PY2023, the application process is as follows:

1. An organization must submit a Notice of Intent to Apply (NOIA) before June 7, 2022.
2. After submission, and once the organization has gained access to CMS’s ACO Management System, it can work on Phase 1 of the application from June 8, 2002, through June 29, 2022.
3. Next, over the course of the following months, the organization will have the chance to respond to requests for information from CMS and submit Phase 2 of the application (from October 13, 2022, through October 20, 2022).
4. If the organization successfully meets all application criteria and is selected to participate in MSSP by CMS, it will take part in an ACO signing event during December 2022, where the organization will be able to review, certify and electronically sign documents related to its MSSP participation.

Why is it a good time to finally participate in MSSP?

This past year, the CMS Innovation Center issued a refreshed strategy, with the goal of achieving equitable outcomes through high-quality, affordable, person-centered care. To achieve this vision, it outlined five strategic objectives that will guide their future payment models, with the first objective being “Drive Accountable Care.” This strategic objective specifically states that all Medicare beneficiaries with Parts A and B will be in a care relationship with accountability for quality and total cost of care by 2030. CMS is clearly stating that some form of accountable care will be the standard for reimbursing providers in the near future, and given that MSSP is its most tried-and-true ACO, we expect this program to be the administration’s preferred vehicle of accountable care adoption by 2030.

Fee-for-service reimbursement works well for our organization—why don’t we just wait until 2030 to start participating?

For a government agency that, at times, can be overly ambiguous in their policies, CMS is being refreshingly intentional in their messaging around accountable care—but why? We believe it’s because they’re trying to give organizations ample time to build the infrastructure needed for accountable care programs like MSSP. Building out a value-based care (VBC) infrastructure takes time and requires years of experience and investment in people, processes, and technology to be successful. Additionally, fee-for-service (FFS) reimbursement will likely look much different in the near future. On the professional reimbursement front, the Medicare Physician Fee Schedule has seen dramatic changes over the past several years, and all signs point to continued conversion factor and other reductions driven by MACRA legislation and the continued push for accountable care adoption. Institutional reimbursement is no exception, either, and will likely continue to see reductions to eliminate care appropriate site-of-service differentials and immense fiscal pressure if inflation trends continue at their current trajectory. The good news is that MSSP offers a glide path approach toward downside risk that allows organizations to slowly reduce their dependence on FFS reimbursement while they simultaneously build out their VBC infrastructure.

My organization already participates in MSSP, but we’re concerned with downside risk—what are our options?

When CMS released Pathways to Success changes to MSSP in 2018, it was fairly evident that by using the Basic track glide path approach, they wanted participating ACOs to eventually progress to take on a nominal amount of downside risk. Now in 2022, as CMS designed, many active MSSP ACOs are faced with the choice of moving to downside risk in PY2023 or dropping out of the program. MSSP ACOs we have worked with generally fall into three categories: Still Learning, Succeeding or Experience Challenges.

• ACOs that are Still Learning have had inconsistent success in MSSP but overall haven’t experienced large losses and are gaining experience by participating. Thus, it generally makes sense for these ACOs to continue in the program at the next-lowest level of risk available to them.
• ACOs that are Succeeding have either achieved savings consistently or have been able to avoid repayment of shared losses and have simultaneously built out their VBC infrastructure. Thus, these Succeeding ACOs may want to consider “jumping a level” within MSSP or consider whether ACO REACH is an option.
• ACOs that are Experiencing Challenges have consistently had to repay shared losses and have achieved poor quality scores in the program. For these types of ACOs, we advise evaluating whether there are any positive externalities occurring outside of the ACO. For example, a commonly overlooked positive externality is an ACO that has successfully, appropriately shifted Medicare FFS volume from an IP to OP setting for one of its hospitals but has also gained OP market share and thus increased utilization and, potentially, total expenditures. In this example, while the ACO may not have achieved any savings (and potentially achieved shared losses), the financial benefit of the newly created IP capacity at its sponsoring hospital may have outweighed the shared losses experienced by the ACO. In addition to evaluating possible externalities, ACOs Experiencing Challenges should evaluate their VBC infrastructure to understand if they have made investments that would allow them to ultimately be successful in an MSSP ACO. Ultimately, if the organization isn’t willing to fully get behind value-based care, it may be time to consider exiting the program or restructuring the ACO to achieve success.

Our organization is fully embracing value-based care and the adoption of accountable care and has also been successful in MSSP—what else can we do?

As mentioned above, organizations that have experienced success or have fully embraced the transition to VBC have different options available to them. One option for the Medicare FFS population is ACO REACH, which in comparison to MSSP, offers advanced levels of risk, alternative payment mechanisms for aligning their network and is more similar to a Medicare Advantage plan in some respects. While the PY2023 application for ACO REACH has closed, partnership opportunities with Direct Contracting Entities (soon to be REACH ACOs) exist for certain markets. Alternatively, successful MSSP ACOs may want to look outside of the Medicare FFS population to the rapidly growing Medicare Advantage market, where many of the tools and processes used to manage their aging Medicare FFS population developed under MSSP can be leveraged to achieve similar results in a Medicare Advantage shared savings program.

What should my organization do next?

The decision to participate in an alternative payment model such as MSSP is complex, but Sg2’s expertise—and experience—in value-based care can help your organization power your success across the entire decision process. No matter where your organization stands today on its journey to value-based care, our alternative payment model experts use extensive research to advise you on the right programs to participate in, and then help facilitate successful implementation of these programs. Please reach out to us for more information or to speak with an Sg2 value-based care expert.