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CMS advocates tough love for ACOs

By Shannon Firth
MedPage Today, October 5, 2018

"Risk" and "predictability" were key themes in the discussion between accountable care organization (ACO) participants and Adam Boehler, the recently appointed director of the Center for Medicare and Medicaid Innovation (CMMI).

"There are a lot of folks that should take risk and there are a lot of folks that shouldn't take risk," Boehler said Thursday at the National Association of ACOs (NAACOS) conference here. "And I'm a big believer in being what you are."

One group that probably shouldn't take risk: single physician groups. "That's silly," he said. But for those providers and hospitals who are ready, it's his responsibility and that of the Centers for Medicare & Medicaid Services (CMS) to create "practical and simple" policies to help participants succeed, Boehler said.

And for those who aren't? "It's also our job to say to folks, 'If you're not cutting it, get out of the way,' because there are others that will come that will cut it ... People will come in and take that risk and do something with it," he said.

Boehler's comments are in line with CMS's more aggressive vision for ACOs to move towards risk.

Training Wheels Off

In August, CMS released a proposed rule for the Medicare Shared Savings ACO program which shortened the glide path for ACOs to stay in upside only models (those without any risk) for 2 years, down from an initial 6 years.

NAACOS president and CEO Clif Gaus, ScD, swiftly panned the idea of a shorter transition period, saying at the time that CMS was "pulling the rug" out from under the program.

In May, a NAACOS survey found that 71% of ACO participants would likely leave the Medicare Shared Savings Program (MSSP) rather than take on two-sided risk.

https://www.medpagetoday.com...

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NAACOS: Proposed rule changes to ACO program are 'deal breakers'

By Tina Reed
Fierce Healthcare, October 5, 2018

Proposed changes to the federal accountable care organization (ACO) model—namely, a cut in the shared savings rate from 50% to 25%—would cut the knees out from under the program, board members of the National Association of ACOs said on Thursday.

Speaking with reporters at their annual conference in Washington, D.C., ACO leaders said they supported many of the proposed changes that the Centers for Medicare & Medicaid Services have brought forward regarding ACOs.

But proposed rules that would speed their path to risk and reduce the reward they would reap in return for any savings they realize are "deal breakers" for new entrants to the program, said Clif Gaus, NAACOS president and CEO.

"I don’t know any ACO that would roll the dice for 25%," Gaus said. "You’ve got the carrot and the stick. And you just cut the carrot in half." 

https://www.fiercehealthcare.com...

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Verma, Azar take aim at ‘Medicare for All' proposals

By Paige Minemyer
Fierce Healthcare, October 5, 2018

Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma took another swipe at calls for a “Medicare for All” healthcare system this week, saying expanding those benefits to every American would “dilute” the program.

“Putting more people in the program is not going to solve the problem, and actually threatens the focus and security of the program for seniors,” Verma said.

When FierceHealthcare requested more details on how expanded enrollment would hurt seniors, CMS declined to provide specific data.

Department of Health and Human Services Secretary Alex Azar has also drawn a clear line in the sand on Medicare for All. In a speech last week, hosted by the Nashville Healthcare Council, Azar said that expanding the program to all Americans would eliminate their ability to make health choices for themselves.

“It’s simple math: Higher payments from commercial insurers help doctors take on seniors whose Medicare plans pay less,” Azar said. “It’s far from an ideal set-up, but a single government system would completely unravel it, without a theory for how seniors’ access would be protected.”

https://www.fiercehealthcare.com...

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Comment:

By Don McCanne, M.D.

At last week's meeting of the National Association of ACOs (NAACOS) there was considerable interest in CMS's proposed rule in which accountable care organizations (ACOs) would be forced into downside risk after only two years instead of the previous six allowed, and the share of any savings for the ACO would be reduced from 50 percent to 25 percent, with Medicare keeping 75 percent.

Of course no ACO wants downside risk but that is their stick that drives accountability for costs of health care. If forced into downside risk, the ACOs want time to adjust their operations to meet the required benchmarks, but that time would be cut short by the rule such that most ACOs would anticipate losses. The carrot for sharing in savings also is being reduced in half. An industry survey suggests that close to three-fourths of ACOs would leave the program rather than take on two-sided risk, and you can imagine that there will be a paucity of new entrants into the program, if any at all.

Although the rule is still only proposed, it is well on its way to being adopted since it has the strong support of CMS administrator Seema Verma and HHS Secretary Alex Azar. They are so determined that CMS's Adam Boehler, director of the Center for Medicare and Medicaid Innovation (CMMI), says, "If you're not cutting it, get out of the way."

Oops, where did everyone go?

ACOs have fallen far short of expectations, and now they want to tighten the vise on providers. How could anyone with the least knowledge of health policy ever conceive that this model could succeed? If you consider the provider costs of participating in the program, it has already failed.

As regular readers know there is a proven model that would work for all of us, patients and providers alike - a well designed, single payer, improved Medicare for all. Yet last week both Verma and Azar again have attacked Medicare for all. Can we change their minds, or do we need to replace them?

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