Whether or not accountable care organizations should take on more risk after just one year of experience or after three years in the Medicare Shared Savings Program was the issue the Medicare Payment Advisory Commission addressed at its monthly meeting Thursday.
The Centers for Medicare & Medicaid Services will be releasing new regulations next year for the second round of three-year MSSP contracts beginning in 2015. MedPAC, which advises Congress on issues impacting the Medicare program, leaned toward adding risk in the second three-year contract for ACOs, while leaving providers and other participants in the first three years to focus on learning and adjusting to the rigors of value-based models.
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Currently, ACOs participating in MSSP do not carry risk, while those in Pioneer models take downside risks.
While adding more risk has the potential to drive incentives to achieve quality and efficiency, the committee acknowledged, how much more risk and when requires thoughtful examination. No specific solutions came out of the meeting but the discussion began to shape possibilities.
One concern raised was that if more risk is added, veteran ACOs might pull out of the model, returning to traditional fee-for-service, but commission member Craig Samitt, MD, executive vice president of HealthCare Partners, didn't think that was likely to happen because the veteran ACOs have invested in the infrastructure to become ACOs.
His concern was that by adding risk, organizations thinking about leaving fee-for-service to become an ACO may hold back or decide against it. "We have to make one-sided ACOs more attractive or make fee-for-service less attractive," Samitt said.
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Organizations that are concerned about more risk in general are also concerned about how benchmarks are set, leakage of patients to other providers outside of the ACO and having mechanisms to steer patients to them, noted Glenn Hackbarth, MedPAC chairman.
"If ACOs move to two-sided risk, they need to be more particular about the benchmarks," he said. "An organization that has a low benchmark because of past efficiency is not going to feel good if they are taking losses if their neighbor, which has a high benchmark because of past inefficiency, is making profits," he said.
The goal is to create accountability for outcomes, said Scott Armstrong, MedPAC member and president and CEO of Group Health Cooperative. "We want to make it easy for organizations to enter ACOs … but push harder once they're in," he said. "Yes, there should be two-sided risk, but it could be graduated."