Thread by @Travis_Broome

Diving into the new #ACO #MSSP rule.
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So right off the bat we are talking about a July 1, 2019 start where existing ACOs would extend their current contracts six months and new entrants wouldn't start till July 1. This is disruptive hopefully they left the door open to a Jan 1 start.

Very substantial changes as we thought there would be with the new administration and a long time in coming for the rule. The reg text changes themselves run 78 pages

Moving to a Basic and Enchanced track (although Basic does not appear basic) and 5 year contracts

Basic is levels A-E. Levels C-E require secured risk (all risk taking tracks require it now) and then Enchanced Track does as well. So the only tracks available now without substantial risk are Basic Level A and B.

The Basic track would use the revenue based loss limits (ala Track 1+)

Moving to regional inflation in all years finally does away with the dice roll of national inflation in the first contract. Good riddance to national inflation. We knew you and didn't like you very much.

Liking many things, but 2 disappointments so far. 1) We need to start in Jan. The July start will just complicit everything and 2) Even setting that aside the program looks more complex. Appears some Next Generation ACO style complexity has seeped over to MSSP.

The Enhanced track is essentially Track 3. All the track action is in the BASIC track and its five levels.

Basic glide path levels really embraces the revenue based risk. Certainly a fan of that. ajmc.com/contributor/tr…

Another long awaited proposal. ACOs will now be able to pick between retrospective and prospective assignment.

The glide path in Basic track is flexible. ACOs will be able to move to higher levels of revenue based risk and thus get back to the 50% savings rate faster if they choose. This makes the 5 year length more tolerable bc you don't have to wait 4 yrs to get back to 50.

While there was a much simpler way to deal with the rural ACO market share issue (see ajmc.com/contributor/tr…) at least CMS did deal with it just in its complex, CMS-y way with blended national and regional rates.

Trying to simplify the complexity of the Basic track. Slowest you can go. 2 years no risk, 2 years less than Track 1+, 1 year Track 1+ for a total of 5 years. Fastest you can go. Straight to Track 1+.

CMS discusses concerns about ACO risk coding initiatives, but does propose a 3% symmetrical cap over 5 years so less than 1% change per year which is crazy small, but the symmetry does get rid of the current situation were heads CMS wins and tails the ACO loses.

Moving regional benchmarking to the first contract, but capping the regional adjustment at 5% of the national average expenditures. So a low cost ACO could see more than a 5% lift in their benchmark and a high cost ACO would see less than 5%.

Apparently CMS just can't quit trying to use national averages to try and distort regional variations.

So the new regional benchmarking schedule for an efficient ACO is 35% first 5 yrs, 50% yrs 6-10 and 50% yrs 11-15. For inefficient it is 25, 35, 50.

So you dealing with the market share in regional trend problem rather than removing the ACO benes from the regional trend they would replace national trend with regional trend based on market share. So 20% market share would equal 80% regional trend and 20% national trend

So when it is this close to your business eventually you have to stop tweeting to go to meetings. Will follow up more tomorrow. Final take aways.

1) The July start date is a much bigger deal than I think CMS appreciates. They should have strove for Jan 1, but the ship appears to have sailed.
2) Very happy to see revenue based risk (Track 1+) embraced in the #MSSP proper

3) Risk adjustment does not go far enough. Pleased to see the recognition of changing health, but a 3% cap over 5 yrs is insufficient to reflect reality
4) CMS tried to address the market share issue for rural ACOs, but tripped over their own feet. Just remove the ACO benes...

4) ... The small number problem is a lame excuse. MA has already solved this problem. Just use the MA solution for small numbers and do the simple thing. Please no new complex blended adjustments ripe for unintended consequences.

5) Good to see bonuses based on regional efficiency right away in the first agreement even if we didn’t get the much simpler version of regional benchmarking that we could have gotten.

The real take away is that the details matter. Over the next 60 days the ACO community must dive into the details and be very detailed in their response. We at @AledadeACO will be there and look forward to working with everyone on it.