Farzad Mostashari Profile picture
Aug 30, 2018 26 tweets 10 min read Twitter logo Read on Twitter
1/ 2017 #MSSP #ACO Results!
ACOs have scaled rapidly across the country!

In aggregate, the 472 ACOs were accountable for nearly 9 million Medicare beneficiaries and $95 Billion- that's a quarter of all fee for service, and almost half of the entire Medicare Advantage market.
2/ If you add up all the actual costs versus benchmarks, these 472 ACOs were collectively $1.1B under their benchmarks (more on whether that's the right counterfactual later).

Medicare shared $780 million in payments with the ACOs, netting the taxpayer $313M
But wait!

There's lots of evidence that the benchmark under-estimates the savings produced. @JMichaelMcW et al have shown convincingly that a true "difference in difference" approach would show substantially higher net impact.

The green eyeshades folks at CMS OACT said add 60%
3/ So that means that the best guess for MSSP savings is actually $1.75B in 2017, with Medicare paying out $780M (45%)- not a bad deal for the taxpayer!!!

That does NOT count savings that come from lower costs to the taxpayer from Medicare Advantage rates that are keyed off FFS
4/ Here's how the CMS actuaries put it:
And on quality- the average ACO earned 92% on their quality scores- and the scores improve the longer you are in the program according to the ACO Rule's Regulatory Impact Assesment.

(The Aledade average quality score applied was over 95%, and as high as 99.8% #GoKANSAS)
6/ Lemme say that again....

ACOs saved Medicare over a Billion dollars in 2017.

Cheaper than FFS, cheaper than MA.

And they did it without cutting payments to doctors or narrow networks

And they did it with higher patient quality.

That's called delivering what was promised
7/ the Track 1 ACOs more than held their own here

Best guess is that Track 2/3 generated 190M in savings (w 60% spillover) and received $95M (50%)

Track 1: $1.5B in savings, $685M in payments (44%)

(I'm still a believer in moving to 2-sided risk to help weed out ACO squatting)
8/ You know what was a great investment? Giving small and rural physician-led ACOs an advance payment to help them invest in infrastructure and setup costs.

It was critical to the success of several of our @AledadeACO

More commercial payors should do this!
9/ But what this initial release does not help us do is see which type of ACOs are creating the most value.

My guess is that it's not much different from what the CMS actuaries found for PY 2016- ACOs that include hospitals and directly control more of the cost of care do worse
10/ The "low revenue" ACOs (in the OACT analysis - less than 10% of total cost of care came to them) were only a third of the lives in the program, but generated roughly 98% of the savings.

THAT is why in the ACO Rule CMS proposed letting them stay in low risk models longer
11/ That was the entire thesis behind "the paradox of primary care leadership" that informed the founding of @AledadeACO

That is also why @AledadeACO partners with independent physician practices, not hospitals like others do.

jamanetwork.com/journals/jama/…
12/ A quick analysis by the amazing @Travis_Broome divides these 2017 results by whether the ACOs included a "facility/CCN" (CAH, RHC, FQHC don't count for this purpose) -

Same pattern- 95% of the savings are coming from the ACOs that don't include hospitals.
13/ Only 3.5M of the 9M ACO-attributed benes were cared for by the smaller ACOs that didn't include a hospital facility- and they generated 95% of the savings.

If you're an independent practice seeing these results and the policy direction, why would you join a hospital ACO?
So how did @AledadeACO do?

We are always very transparent with our results- even when things didn't go our way- to look for ways to be better, and to make policies better that are holding back broader success.

This article 2 years ago was full of pain. ajmc.com/journals/issue…
15/ This was a good year for @AledadeACO

Only 1/7 freshmen ACOs made savings- but we have learned to set expectations- it's a long game.

But 5/8 ACOs that were sophomores or older will get checks.

And 2/3 that didn't get MSSP crushed it in commercial contracts.
16/ But I'm more proud that EVERY ONE of our @AledadeACO have measurably improved health for the patients we are accountable for.

We have increased wellness visits, transitional care, and chronic care management- and that's translated into lower ED visits and readmissions
17/ So where do we go from here?

The #MSSP #ACO program has been a hugely successful motivator of nationwide transformation, but it can be reformed, and I believe @SeemaCMS is on the right track.

Here's what I would expect might change between the NPRM and the final ACO rule:
18/ The GlidePath to risk reduces ACO squatting, and brings revenue-based downside risk to MSSP, but the lowered gainshare in 1st 2 years (25%) is not enough to get new entrants and ACO investments.

(as suggested) "low revenue" ACOs should get higher gain-share and lower MSR
19/ The refined benchmarking method gives greater predictability by allowing risk adjustment and regional trending-which is great!
But the cap on risk adj (3% over 5 years?!) don't control for rising risk and introduces gaming on falling risk

Instead of a cap, do renormalization
20/ Concern about "windfall profits" led to an ill-advised proposal to cap regional efficiency at 5% - In Medicare Advantage if you are efficient, you get to keep the difference, which has spurred huge innovation in the space. why blunt improvement? 100% tax brackets are not good
21/ Credit to CMS for trying to fix the unintended "regional comparator" problem- where rural ACO savings are reduced in direct proportion to market share. But the "national trend blend" proposal makes NO SENSE.

Let's just take ACO benes out of the regional comparison please!
22/ But the biggest impact of these results on the proposed rule should be on the idea that the way to benefit the Trust Fund is to protect it from ACO earnings.

These caps, etc reduce ACO earnings- and ACO motivation/participation- and therefore reduced benefit to Medicare
23/ The NPRM RIA estimates through 2024 these caps push $390M in lower ACO earnings, but lower ACO participation under these policies will INCREASE claims costs by $60M- and would prevent beneficiaries from receiving the benefits of the program. That's not the right balance
24/ The magic of accountable care is when physicians & Medicare partner together to sustainably align financial incentives, help beneficiaries and the Trust Fund.

Medicare hasn't behaved like some commercial payers who are still seeing zero sum. Let's hold onto that partnership
🦄🌈🦄🌈

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More from @Farzad_MD

Jul 26, 2018
It's strange that everyone on health policy twitter is not going apes over the Hospital Outpatient Prospective Payment System (#OPPS) rule released today

It contains one hugely significant proposal that hospitals will fight bitterly...but could actually help them in the long run
Background- there are two different CMS payment systems for historic/operational reasons, one for professional services, and the other for hospital outpatient depts.

Up until now, there had never been an effort to make sure that equivalent services would have same payment rate.
In fact, the same procedure paid for in hospital OPD setting ended up being reimbursed at a much higher rate than the exact same procedure at a doctor’s office.

Here’s how @MartinSGaynor and Paul Ginsburg and I described it in our “Making Markets Work” White Paper
Read 13 tweets
Apr 25, 2018
1/ A little bit of history here…

When I was national coordinator for health IT, we did an RFI with CMS for “Advancing Interoperability and Health Information Exchange"

federalregister.gov/documents/2013…
2/ If you’re a student of this stuff, it’s pretty topical- including a section on patient-centered information exchange on promoting #BlueButton - including through Medicare Advantage, … which is now on the verge of becoming a reality
3/ Another idea I was pretty excited about was using inpatient/post-acute Conditions of Participation as a vehicle for getting information sharing - on the argument that it really is a basic health and safety requirement
Read 11 tweets
Mar 6, 2018
1/ There was a very important speech today by @SecAzar today at the @FedAmerHospital that I'm going to annotate for you.

Anyone who’s been waiting for a clear declaration of this Administrations beliefs and intentions re #ValueBasedCare - here it is

hhs.gov/about/leadersh…
2/ @SGottliebFDA is killing it at @US_FDA
and everyone loves @NIHDirector precision medicine stuff
who's to say @SeemaCMS can't make delivery reform happen faster?

---->"This is no time to be timid"
(translation, some people aren't going to like this, and we don't really care)
3/ Our spending on Medicare and Medicaid has tripled since I was last at the Humphreys Building, and while I understand that sounds fantastic to all you hospital folks, I assure you, we're not happy about it.
Read 20 tweets
Oct 19, 2017
Here are the 2016 #MSSP #ACO results you’ve been waiting for. Results are very different for physician-only

#Physician_Led_ACOs_Kick_Butt
Sometimes the rainbows and unicorns are right in front of you
@amitabhchandra2 @Michael_Chernew @C_Garthwaite @JMichaelMcW
…And these #ACO savings are in the context of super-low per capita Medicare national inflation of about 1% per year @porszag
Read 5 tweets

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