Joining the Medicare Pathways to Success Program

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The next opportunity to join the MSSP will be in January 2020, when the program returns to its typical schedule of ACOs joining at the start of the calendar year. You can find more information about the application process, which opened July 1, on the CMS website.

For providers considering joining Pathways to Success for the first time and current ACOs considering whether to continue in the program, here are some questions to consider:

  1. What can we do to forecast our potential financial outcomes (savings or losses)?
  2. How can we prepare to obtain shared savings, and, if applicable, minimize our losses?
  3. Overall, how can we prepare for success in the Pathways program?

Furthermore, new entrants must understand several key variables and MSSP program design elements. Chief among them are attribution methodologies and the ability to estimate beneficiary volumes to support forecasts of cost and quality performance.

7 strategies to adopt

Once enrolled, ACOs should focus on seven key areas to significantly improve their probability of success in the new program:

  • Reduce avoidable admissions, readmissions, and ED visits through care management.
  • Improve diagnosis coding to capture HCC codes.
  • Promote annual wellness visits to patients.
  • Implement a post-acute strategy with strong alignment/preferred lists, and focus on poor utilization and quality.
  • Develop an ambulatory strategy to increase access (e.g., urgent care, outpatient testing, etc.).
  • Develop care-intervention programs around chronic conditions (e.g., diabetes, COPD, coronary artery disease, heart failure, etc.), and reduce clinical variation.
  • Implement an analytics framework to report and analyze the data around quality measures, cost data, and risk.

From there, the task at hand is to implement tactics that will support those strategies.

Tactics to ensure success

Prepare for the CMS Quality Audit Process

For new entrants into the program, preparation for this prescriptive process is a key for success. CMS will provide a subset of beneficiaries, measures, and a time frame to complete the audit (typically between late January and late March). Some measures are aggregated by CMS through claims or via a CMS-approved CAHPS vendor, but it is important to understand that completing the part of the audit that requires your direct participation will require a medical record audit. It is imperative that ACO participants cooperate fully and allow access to their medical records for the identified beneficiaries CMS provides.

In performance year 2017, the average ACO quality score was 90.5 percent, according to NAACOS. In general, existing ACOs have used past performance results to indicate where they have the most opportunity for improvement.

Get population risk-adjustment right

Knowing how CMS calculates your ACO’s financial benchmark for your beneficiary population is critical to success in the program. Creating an annual wellness visit program that encourages providers to reach out to rising- and high-risk beneficiaries is a winning strategy.

In these visits, accurate ICD-10 coding and review of all medical conditions can lead to better HCC capture, which will inform CMS of the true risk adjustment for your population. This will ensure that the correct financial targets are set, giving the best opportunity for success.

Let the data lead

It is critical to develop an analytics mindset, letting the data point you in the right direction to achieve the most significant outcomes. ACOs will receive annual Claim and Claim Line Feed (CCLF) files that are information-rich and lend themselves well to analysis. Knowing how your ACO compares on acute admission and ED utilization/costs is very important. Because avoidable hospital stays and ED visits can create a burden on an ACO’s financial performance, this insight can inform if immediate action is required.

These are just a few more granular tactics and recommendations in support of the seven strategies outlined previously.  Remember this: Focus, measurement, and action will be keys to achieving success in Pathways to Success.

Forecasting the Impact of Quality on Shared Savings Potential

A key element in this process is to forecast shared savings potential and downside risk. The first step is to gather historical data for quantitative measures such as cost per beneficiary per year, admissions per 1,000, readmissions, emergency department (ED) visit percentages, the 13 accountable care organization (ACO) quality measures, and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Because past performance is the best predictor of future results, it is possible to accurately project future performance trends using the MSSP program guidelines for maximum shared savings. For example, using historical and current data from your electronic health record (EHR), it is possible to forecast future performance of the 13 ACO quality measures (see chart below) across high-volume group practices within the future ACO. Once you have this level of quality detail and projected performance, you can assume the range in which your overall total quality score will land and calculate the impact of quality on shared savings.

Finally, regarding shared savings, it is important to develop an estimated per beneficiary per year benchmark for annual spend. Unfortunately, CMS does not make this information available for your attributed lives until after your full application is submitted. However, it is possible to use available historical metrics and published state averages.

Many current and potential future ACOs have begun to forecast both upside opportunity and downside exposure based upon the limits published by CMS for the Basic tracks. By either knowing or estimating the size of your beneficiary population and corresponding minimum shared savings and loss percentages, forecasts of future performance can be estimated.

Forecasters will need to factor in their likely quality score (90 percent is a good standard), as well as the 2 percent sequestration withhold on final savings calculations. Once the potential shared loss exposure is known, ACOs can build their strategy for reserving funds and/or obtaining loans, lines of credit, or reinsurance to satisfy CMS requirements for backstopping potential losses. It is important that all participants understand the downside risk potential and what their ACO’s financial responsibility is, and the methodology employed to distribute such risk.

Lumina Health Partners can help you succeed

The decision about whether to participate in CMS’s new MSSP, Pathways to Success, requires leveraging data and quantitative analysis to project associated risk and returns. Besides understanding the rules of the program, ACO leaders need to understand the cost target, quality rating, and associated risk score they would assume. This allows them to predict financial performance and the funding reserves that would need to be built.

At Lumina Health Partners, we are working with several ACOs across the country to help identify their risk exposure and, more importantly, create a blueprint to help guide the ACOs into shared savings. We created an operationally driven quantitative impact analysis under the new Pathways to Success program. Our assessment approach includes the following components:

  • Leveraging data to assess historical performance against benchmarks.
  • Identifying and/or projecting the number of beneficiaries.
  • Identifying areas of improvement that will affect the ACO and optimize its performance.
  • Calculating potential savings and losses across all MSSP levels.
  • Creating cost, quality, and risk levers to predict future impact and risk.
  • Creating a financial model for executive leadership
  • Identifying the starting point for ACOs as they build their operational infrastructure in year 1, and where they need to focus attention in year 2 and beyond.
  • Creating recommendations for leveraging current and potential added resources to ensure financial stability and success.
  • Creating recommendations regarding evidence-based approaches to bend the cost curve.

These outcomes will allow you to make informed decisions that are in the best interest of provider members and to ensure sustainable financial performance under the new rules.

The decision to participate in the new Pathways to Success program beginning in 2020 requires speedy and thorough information gathering and data analysis to forecast financial and quality outcomes.

To be successful in the new program, ACOs must develop and extend new organizational and management capabilities. From care management to analytics and clinical redesign, these new capabilities are essential to succeed.

John Malone

By John Malone

John specializes in developing and activating strategic performance-improvement initiatives by combining his passion for analytics, change acceleration, and leadership development.