Healio Special Report: Health Care and Politics

Healio Special Report: Health Care and Politics

August 14, 2018
3 min read

ACP: CMS ‘Pathway to Success’ is a bumpy one

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The American College of Physicians said in a press release there were good things and bad things about the new CMS plan known as Pathways to Success — a plan the federal agency said overhauls rules for Accountable Care Organization in the Medicare Shared Savings Program established by the Affordable Care Act.

The new initiative moves toward paying providers for the value of care, not just volume of services, Seema Verna, CMS Administrator, said in a conference call with reporters last week. She said this long-standing bipartisan concept is borne from the idea that health care costs are rapidly bleeding federal and personal budgets dry.

“For years we have heard from policy makers from both political parties talk about [this need],” she said. “This need is borne from the reality that our health care is growing at an unsustainable rate. If we continue on this path, by 2026, one in every $5 spent in our economy will be on health care, which will crowd out other funding priorities like public safety, infrastructure, national defense, and education ... and for every American, this will strain our household budgets with higher premiums, copays and deductibles.”

More than 80% of shared savings ACOs are currently in a status where they “have no incentive at all to reduce health care costs while improving health outcomes” and are exempt from federal laws and requirements, Verna added.

According to a CMS press release, ‘Pathways to Success’:

  • Limits the time that an ACO can stay in the program without taking on risk down to a maximum of 2 years;
  • Requires that beneficiaries receive a notification at their first primary care visit of a performance year informing them that they are in an ACO and describing what that means for their care;
  • Leverages new CMS powers under the Bipartisan Budget Act of 2018, such as allowing ACO-enrolled physicians that take on risk to receive payment for telehealth services provided to patients no matter where the patient is located;
  • Promotes interoperability and patient control of their medical data by proposing a new requirement around ACO adoption of the 2015 edition of Certified EHR Technology (CEHRT); and
  • Incorporates regional spending into ACO targets earlier, starting during an ACO’s first agreement period and authorizes termination of ACOs with multiple years of poor financial performance.

‘Pathway to Success’ could potentially save $2.2 billion in Medicare costs during the next 10 years, CMS stated.

ACP weighs in

The ACP shared its “significant concerns” about ‘Pathways to Success’ in a statement. These are:

  • Cutting the ratio of savings ACOs are allocated to share in by up to half;
  • Allowing only an ACO to remain in a one-sided risk track, under which they are not subject to potential losses for a maximum of 2 years;
  • Blocking ACOs from counting their cost to participate in the program as part of their financial risk — these costs average $1.6 million annually; and
  • Making the proposed changes effective less than 11 months from now.

“The proposed changes to the [Medicare Shared Savings Program] are significant and may disincentivize physicians and other health care professionals to participate in the program,” Ana María López, MD, MPH, FACP, ACP president, said in the statement.

Conversely, the College said in the statement that there were several components of the CMS proposal that were in line with ACP’s longstanding requested revisions. Those are:

  • Phasing in a new approach to setting benchmarks faster, which would avoid penalizing ACOs in high-expenditure areas;
  • Adjusting risk more accurately by accounting for declines in patient health status over time, so that ACOs are not unfairly penalized for spending more on patients whose conditions have worsened; and
  • Allowing any ACO to choose to have their patient population assigned at the beginning of the year (ie, prospectively), if they would rather that methodology instead of the current retrospective approach to patient attribution.

CMS is accepting comments on the proposal until Oct. 16, 2018. Please see the instructions on the Federal Register. by Janel Miller

Disclosure: Verna is CMS administrator; Lopez is president of ACP.