By Abbas Bader

As most of you are already aware, CMS released a rule proposing changes to the Medicare Shared Savings Program earlier this month.  By now, you have probably read several summaries of the key provisions of the rule, if not the full 607 pages of the rule itself.  In a webinar a couple weeks ago, CareJourney President, Aneesh Chopra, led a discussion with our members that sought to go one level deeper than just these key provisions.  The goal of the discussion was to distill the proposed rule changes into a set of key questions that ACO staff may currently be grappling with. While CareJourney does not claim to have a silver bullet or a magic wand when it comes to ACO strategy, we anticipate that this is the type of debate that will put existing Medicare Shared Savings Programs on the “Pathways to Success” that this rule repeatedly references.

Question #1:  What is my ACO’s attributed population? 

As basic as this question sounds, it is still one of the most difficult for an ACO to answer. The proposed rule offers new flexibility such as the ability to opt into prospective beneficiary assignment each year regardless of the track the ACO is in.  Whether or not an ACO decides to pursue levers such as prospective attribution or even voluntary alignment should depend on a deeper understanding of an ACO’s historical attribution experience.  Two critical pieces of information here are the stabilityof the continuously assigned population in an agreement period as well as the alignment of the attributed population with the strengths of an ACO.

Question #2:  How is our ACO Defined for the Glide Path?

CMS laid out two concepts that will help ACOs understand their glide path to downside risk. The first is the idea of “experienced” vs “inexperienced”, for which an ACO must understand the history of their participant providers in other programs, such as the Pioneer ACO, CEC model, and others.  The second is the idea of “low revenue” vs “high revenue”, for which an ACO must understand the breakdown of their revenue by their participant list.  The definition of the ACO by these two components defines the number of years the ACO can stay in the BASIC track before having to move into the much steeper downside risk of the ENHANCED track.

Question #3:  What choices do we have to redefine our ACO?

Given the above definitions are based on a defined set of participants, it is important to consider what changes to that list of participants will mean for the ACO. In order to effectively make any re-design decisions about the ACO as a whole, the organization must understand both existing partners and participants as well as potential partners and participants with whom they may want to align themselves in the future.  Learn more about our access to the national CMS dataset to see how CareJourney can assist you with that exercise .

Question #4:  How can we leverage new waivers to better serve patients?

One of the most talked about new provisions in the proposed rule is the ACO’s ability to offer beneficiary incentives to encourage medically necessary services. This, along with the increased access to telehealth and SNF waivers should prompt ACOs to ask important questions about which segments of their population can benefit most from these new services.  Our continued support for open-source and clinically relevant methodologies has led us to the High Need High Cost segmentation model from the National Academies of Medicine.

Question #5:  How does the rule advance the MyHealthEData initiative?

There are two components of the proposed rule that will advance the MyHealthEData initiative. First, the proposed rule promotes interoperability and enhanced patient control of medical data with a new requirement for ACO adoption of 2015 edition of Certified EHR Technology (CEHRT).  Increased interoperability leads to a more patient-centric healthcare system by breaking down barriers to health data.  Additionally, the proposed rule will lead to improvements in the Meaningful Measures initiative by focusing quality measures to reduce provider reporting burdens and to improve data sharing.

As those of you who follow CareJourney may be aware, we are very optimisticabout the role that ACOs can play in reducing the administrative burden of providing beneficiary’s access to their data.  Contact usto learn more about how we are working with our newest clients to leverage the CMS Blue Button API to make this dream a reality.

Here at CareJourney, we value our role as a trusted data partner to over 50 member ACOs. Therefore, we posed five critical questions to members with the goal of understanding the following for each question: (1) the relevance of that question for the membership, (2) the information needed to determine the ACO’s strategy (3) the actions that could be taken when that information is presented.  Our hope is to leverage the feedback from conversations like this to continue providing relevant, actionable information that our members can use to be successful.


Click to view Member Discussion on CMS Proposed Rule | PDF file (1.1mb)