Thread by @Farzad_MD

1/ CMS released an Interim Final Rule w Comment that include a sweeping range of changes to payment policies for physicians, hospitals, hospice providers, labs, and a whole lot of abbreviated providers (FQHC/RHCs/CAHs/CMHCs/IRFs/LTCH/SNF/HHA/DMEPOS)

I'll just talk about MSSP now

https://twitter.com/SeemaCMS/status/1255915459603501056

2/ I'll start by pointing out that an extraordinary amount of work was done here by very dedicated, smart, and diligent civil servants in a very short amount of time to move billions of dollars around, to try to mitigate the impacts of COVID19 on the healthcare system

hats off

3/ and as they point out numerous times, there was no time to do a proper regulatory process, with proposed rules and comment periods and analysis- hence going right to an "IFC"

But this also shows why getting feedback on ideas before finalizing regs is so important (APA 🇺🇸)

4/ Now, the Medicare Shared Savings Program is actually amazingly resilient. The benchmarks are adjusted retrospectively to match regional and national trends

The program doesn't need a $175B bailout like fee for service has-it will keep SAVING $ for CMS

aledade.com/how-mssp-progr…

5/ But the extreme anomaly that is 2020 healthcare raised 3 questions-

*Would there be protections for ACOs in downside risk contracts?

*How they would account for 2020 attribution as the volume of in-person visits has dropped

*How to set benchmarks for 2021-start ACOs?

6/ A lot of hospital ACOs in downside risk contracts got worried about having to pay huge losses. Not because there was any data or math suggesting it (there isn't)- just because of fear around what extreme variability might do

They asked CMS for relief

We @AledadeACO didn't 🤷

7/ So CMS said that they would use the program’s "extreme and uncontrollable circumstances policy" to mitigate shared losses for the period of the COVID19 Public Health Emergency- shared losses would be pro-rated for however many months it lasts (likely all 12 months of 2020)

OK

8/ The actuaries believed that up to a third of ACOs might have dropped out of the program if they hadn't reduced downside risk (including by letting ACOs stay in their current tracks)

that dropout rate would have cost Medicare $90M-$290M (because the program makes money)

9/ Actuaries believed that expenditures would be down 20% (!) but variability (SD) would double.

Some areas will be harder hit than others, and the difference between regional and national trends could be significant. That could create inequities

aledade.com/deep-dive-how-…

10/ So they proposed to reduce it by removing the costs of COVID treatment - in fact, completely excluding the affected months from per capita expenditure calculations

A better solution would be to just go to purely regional trends, fix the "rural glitch"
aledade.com/aledade-physic…

11/ Next up they expanded the definition of "primary care services" for determining beneficiary assignment to include telehealth codes for virtual check-ins, e-visits, and telephonic communication-Good

Another way would have been to make a 2 year look-back period for attribution

12/ But here's the doozy.

How would you set benchmarks for 2021-start ACOs, given the unusual cost experience of 2020 (BY3 usually counts for 60% of the historical benchmark)?

We had some ideas, but there was no comment period

You could look at 17/18/19, and add a 2-year trend

13/ There's precedent for that. The Next Generation ACO program benchmark years were basically frozen for years.

ajmc.com/contributor/tr…

You could just skip over the anomalous year of 2020, prevent "windfall profits" (though 2020-2021 trend would have solved a lot of that too)

14/ But instead, THEY CANCELLED THE 2021 SEASON

That's right. 10 years of building participation across two administrations, of the most successful value-based program we've got, adding over a 100 new ACOs (>1M new benes) a year

And they said, no new ACOs at all for 2021

What?

15/ And there was no warning, no discussion, no opportunity to provide alternative means of achieving shared policy goals.

But what's most galling?

"because this will allow ACOs and their ACO providers/suppliers ...to continue focusing on treating patients during the pandemic"

16/ KEEPING PATIENTS SAFE AND AT HOME IS THE WORK OF THE ACO

If you call yourself an ACO and you think that during the pandemic your staff and doctors should be focusing on other work, I'm sorry, but there might be something wrong with your ACO's activities and goals.

17/ What we've been doing is finding PPE for our docs so they can continue to deliver care, do parking lot testing

Launching telemedicine so primary care can continue

Communicating with patients so they can stay home and safe and "Call us First" before going to the ED

ACO work

18/ All of these things will make your patients less likely to be hospitalized during COVID. If you can do that, you will generate savings for Medicare versus the region, and you will be less reliant on FFS

ACO work is COVID-related work right now

And chronic dz are still here

19/ It looks like there will be no new ACOs in 2021.

But you can add practices to existing ACOs.

We @AledadeACO have 38 of them.

And we will take every last independent primary care practice who wants something better for their patients, for their practices, and for society