The COVID-19 pandemic has considerably challenged clinician practices, hospitals, and all well being care supply organizations. Many such organizations have scrambled to construct new capabilities and shift workflows to check, hint, and handle COVID-19 in addition to remotely handle continual situations for his or her non-COVID sufferers.
On the similar time, well being care supply organizations are going through appreciable monetary struggles, with elective procedures and non-urgent workplace visits down by 70-80 p.c in lots of practices. Consequently, organizations receiving fee-for-service (FFS) funds have seen their revenues decline precipitously. This lack of capital impacts their capacity to adapt and reply to the pandemic.
The well being care supply organizations which have finest been in a position to work via the pandemic have been these taking part in additional superior different cost fashions (APMs). Recognizing the challenges clinicians and supply methods are going through, the Facilities for Medicare and Medicaid Providers (CMS) on April 30 introduced a number of regulatory adjustments to cost fashions in response to the pandemic. These included a number of vital flexibilities to assist Accountable Care Organizations (ACOs) keep within the Medicare Shared Financial savings Program (MSSP) and take care of sufferers. For instance, ACOs with contracts expiring in 2020 might be prolonged for an additional yr, and ACOs within the BASIC monitor can stay of their present threat stage for an additional yr with out progressing
Nevertheless, not all components of the proposed rule transfer towards the broader objective of extra person-centered cost methods that enhance care, together with for COVID-19. This submit analyzes the proposed rule and recommends methods to enhance it. Particularly, we urge CMS to permit new ACOs to hitch the MSSP within the 2020 software cycle, and we recommend ways in which CMS might tackle its considerations concerning calculating benchmarks for these new ACOs within the uncommon situations attributable to the pandemic. We applaud CMS’s choice to depend sure telehealth visits towards attributing sufferers to specific ACOs, however we additionally define methods to guarantee that this neither will increase disparities amongst enrollees nor unduly some ACOs over others.
We suggest that Congress act to permit CMS to revive a sophisticated cost model that would offer funds for cash-strapped ACO to construct up their telehealth functionality and different care administration competencies. We help CMS’s choice to not depend prices for COVID-19 hospitalizations and outpatient care within the month following discharge in calculating shared financial savings and losses for ACOS, however significantly since many COVID instances are usually not accurately coded, we suggest that CMS affirmatively monitor ACOs with excessive COVID burdens. Lastly, we clarify how utilization decreases attributable to COVID-19 may undermine present ACO high quality measures, and we provide ways in which CMS may cope with this.
Extra broadly, the first coverage priorities needs to be to allow extra well being care supply organizations to construct higher care methods for the pandemic and past, and to make sure that well being care supply organizations stay financially viable regardless of monetary losses from utilization declines. Each priorities may very well be achieved via APM flexibilities and helps that assist organizations transfer away from FFS.
How Different Fee Fashions Have Helped Well being Care Supply Organizations Climate The Pandemic
APMs have typically allowed well being care supply organizations to revamp their workflow, supply wanted companies and approaches in response to the pandemic, and leverage the competencies and infrastructure they constructed to handle the APM. For instance, organizations are re-purposing care coordinators for testing and monitoring COVID-19 sufferers, utilizing their inhabitants well being administration knowledge methods to determine high-risk sufferers needing COVID-19 testing, or using telehealth and in-home companies to offer continual care companies. As well as, organizations with extra potential and international funds have been higher in a position to financially survive the pandemic as these fashions decouple income from service quantity and provides the group monetary flexibility to ship companies primarily based on their inhabitants’s wants.
In sum, the pandemic has made it clear that APMs have been useful in selling higher inhabitants threat administration and avoiding the monetary challenges related to FFS throughout social distancing within the pandemic.
Proceed Alternatives For New ACOs To Be a part of And Transfer Ahead With Different APMs
As famous above, many clinicians receiving FFS cost are struggling resulting from considerably declining revenues on account of cancelled procedures and workplace visits. Many practices are in critical monetary hassle, with a number of furloughing workers. Consequently, extra clinician practices are investigating APM choices that transfer away from pure FFS and decouple quantity from income.
Whereas there are a number of coverage actions being taken to help clinicians and supplier organizations throughout this difficult time, APMs may help stabilize the well being care system to make sure practices will stay open after the pandemic, thereby making certain Medicare beneficiaries proceed to have entry. Furthermore, APMs (together with ACOs) have allowed clinicians and their well being care supply organizations to offer higher inhabitants well being to COVID sufferers via figuring out high-risk sufferers, coordinating care outdoors of amenities, and offering in-home companies.
Nevertheless, within the interim last rule CMS proposed forgoing the 2020 software cycle to permit new ACOs to hitch in 2021. Sadly, which means that clinicians now prepared to maneuver into value-based cost fashions are encountering closed doorways simply as they’re . Freezing new ACOs goes in opposition to the coverage precedence of enabling extra organizations to get well from present monetary losses and serving to them construct higher care methods for the pandemic and afterwards.
ACOs are sometimes a great way to start out in value-based cost, as this system offers time for practices to study the capabilities they should succeed. Provided that success in value-based cost fashions typically takes years, you will need to get suppliers into APMs as rapidly as doable. Additional, ACOs may give practices the pliability wanted for profitable public well being administration of COVID-19.
Coping with the benchmarking drawback. For the above causes, CMS ought to rethink forgoing the applying cycle for 2021 entrants. Within the proposed rule, CMS notes the motivation for not having new ACOs was that it could be troublesome to calculate the ACO’s benchmark given the weird follow patterns occurring on account of COVID—each elevated utilization for people who get the illness and decreased utilization of elective take care of the broader inhabitants. But, there are a number of coverage actions that CMS might take to account for this problem.
CMS might use an alternate benchmarking method for 2021 new entrants. They may use 2017, 2018, and 2019 as benchmark years 1, 2, and three, respectively, that are then trended ahead utilizing the regional and nationwide development components to create the general benchmark. As well as, 2021 ACOs would want to make use of retrospective attribution of Medicare enrollees, as potential attribution would use care patterns from 2020 to determine the ACO’s inhabitants. The retrospectively attributed inhabitants would then be used for calculating the historic benchmark from 2017–2019.
One other coverage choice to offer an ACO on-ramp can be to permit new ACOs to hitch beneath an extended efficiency interval, reminiscent of 24 or 36 months as a substitute of the present 12-month interval. The longer efficiency interval would enable an ACO to point out results on inhabitants well being, as many interventions take longer than 12 months to point out outcomes. Additional, the longer interval would enable the ACO to common utilization and inhabitants well being over the COVID-related durations.
This may necessitate superior cost, as ACOs wouldn’t see shared financial savings for an extended interval. Nevertheless, there’s precedent for superior cost from CMS, and superior cost can be useful for organizations going through cash circulation crunches. This new entrant method may very well be operationalized equally to Monitor 1+, which was a part of the MSSP however technically applied via a CMS Innovation Middle program. (Monitor 1+ resembles the entry-level Monitor 1 however with added parts reminiscent of some draw back threat and potential beneficiary project.) Following the same tact, if CMS doesn’t wish to have entrants into the formal MSSP for 2021, new entrants into an ACO program may very well be accommodated via the Innovation Middle.
Transferring Ahead On Different APMs. Past offering alternatives to hitch the Shared Financial savings Program, CMS ought to proceed current APMs, launch APMs within the pipeline, or take into account creating further APM choices. Nevertheless, preliminary indications are that some APMs are being paused. For instance, it seems that Direct Contracting (which offers potential, international funds) might be delayed, which takes away one other accountable care choice for organizations. On the present APM entrance, CMS might implement one other spherical of Major Care First functions to offer a brand new choice for suppliers eager about capitated major care funds. Whatever the model, there’s a want to offer choices for clinicians and supply organizations trying to take part in APMs.
Precisely Attribute Sufferers Who Are Receiving Distant Care Throughout Pandemic
As fewer sufferers are receiving in-person care resulting from COVID-19, it’s troublesome to attribute folks to an ACO, which is mostly primarily based on well being care claims for major care companies. Nevertheless, extra sufferers are receiving telehealth companies, which haven’t beforehand counted in direction of affected person attribution.
Utilizing MSSP claims knowledge, in Exhibit 1 we simulated what may occur on account of lowered major care companies. One main result’s that wholesome folks, who may have just one major care go to in a yr, can be much less more likely to be attributed to an ACO. Column 2 reveals the common risk-adjusted annual per capita prices for the MSSP for 2019 for various classes of individuals enrolled in Medicare, assuming no adjustments in major care visits. Column three reveals what would occur to the MSSP’s risk-adjusted annual per capita prices in 2019 if half the folks with just one major care go to per yr weren’t attributed to an ACO, as a result of these folks lowered their major care resulting from social distancing and different causes.
Exhibit 1: Estimation of how adjustments in attribution have an effect on MSSP expenditures.
Supply: Writer (Travis Broome/Aledade) evaluation of Medicare Shared Financial savings Program ACO claims knowledge utilizing the CMS Digital Analysis Information Middle.
We discovered that, for all classes of Medicare sufferers, the calculated annual per capita prices of the common ACO would enhance as they’d be answerable for a sicker inhabitants (because the more healthy individuals who use few well being care companies are much less more likely to be attributed to them). This impact interprets to a 1.06 p.c enhance for ESRD sufferers, a 1.60 p.c enhance for dual-eligibles, a 4.25 p.c enhance for disabled sufferers, and notably a 4.59 p.c enhance for aged, non-dual sufferers (by far the most important group of sufferers). Additional evaluation on the particular person ACO stage is required, as there’s a complicated course of for calculating a person ACO’s risk-adjusted annual per capita prices (together with the healthiness—or threat rating—of the ACO in comparison with the nationwide common).
To treatment this drop in in-person major care utilization, CMS introduced that sure telehealth companies (as flagged by codes for digital check-ins, e-visits, and phone communications) will depend in direction of beneficiary attribution to assist make up for lowered face-to-face visits and hold sufferers protected at dwelling. It is a constructive change, as some stage of telehealth attribution appears vital resulting from new care patterns within the pandemic. It additionally encourages ACOs to maintain wholesome sufferers at dwelling, defending each sufferers and well being care personnel.
Whereas attribution through telehealth is helpful, there’s a want to make sure that this doesn’t deepen disparities, particularly because of the digital divide mirrored in restricted broadband in rural areas and knowledge constraints for smartphones for low-income populations. One other problem is that some more-advanced ACOs may be extra more likely to supply telehealth; due to this fact, sufferers who had been beforehand a part of one other ACO (or unattributed to any ACO) may be attributed to those more-advanced ACOs. Moreover, as famous earlier, wholesome sufferers may forgo care altogether in the course of the pandemic, creating one other attribution problem because the inhabitants of “assignable” sufferers may drop or grow to be sicker on common.
Furthermore, the heterogeneity of ACOs, their populations, and their utilization traits, which is able to differ primarily based on COVID-19 prevalence and authorities insurance policies on social distancing throughout the nation, signifies that the consequences of telehealth use on ACO attribution might differ considerably resulting from components outdoors of their management. For instance (or sensitivity evaluation) of how this might play out inside a specific subset of ACOs (32 Aledade physician-led ACOs), we examined what would occur if half of the ACO sufferers (who’re in Medicare resulting from age) with just one major care go to per yr weren’t assigned to an ACO (say as a result of they didn’t go to their physician resulting from social distancing). For these ACOs, we discovered minimal variation in whole price of care relative to their area (-1.2 to 1.1 p.c, common of -0.16 p.c) and nationally (-1.three to 0.9 p.c, common of -0.55 p.c) resulting from these adjustments in affected person attribution. (Supply: Writer [Travis Broome/Aledade] evaluation of Aledade’s Medicare Shared Financial savings Program ACO claims knowledge utilizing the CMS Digital Analysis Information Middle.) Whereas this instance group of ACOs confirmed minor variation in prices resulting from altering attribution (particularly in comparison with the 4.59 p.c change in price for the related affected person class in Exhibit 1), different ACOs with totally different affected person populations or distinctive implementations of telehealth (reminiscent of out-of-state utilization) might expertise larger adjustments in whole price of care.
Subsequently, to evaluate potential unintended penalties of telehealth attribution, CMS ought to study variations in telehealth uptake throughout COVID utilizing present claims knowledge (and recognizing claims knowledge delays), by way of outliers in sufferers’ use, physicians’ use, and ACOs’ use.
If CMS identifies unintended penalties on attribution (whether or not for retrospective attribution for 2020 or potential attribution for 2021), there are a number of potential coverage approaches to beat them. If smaller or much less technologically superior ACOs have considerably decrease attributed populations, CMS might use a 2-year attribution interval as a substitute of the present annual attribution, which might assist common out adjustments in utilization resulting from COVID, reminiscent of utilizing a unique ACO resulting from telehealth capabilities. If ACOs with important telehealth capabilities see considerably bigger attributed populations, particularly removed from their conventional geographic service space, CMS might restrict affected person attribution for an ACO for 2020 to the counties the place the ACO had attributed sufferers in 2019 (accounting for any adjustments in taking part suppliers that may have expanded the ACOs’ service space).
Lastly, CMS might additionally calm down the present restrictions on adjustments to an ACO’s general threat rating in the course of the pandemic to account for adjustments within the attribution inhabitants. Presently, particular person ACO’s threat scores can go up solely three p.c per yr and due to this fact may not totally account for a brand new inhabitants’s elevated (or decreased) threat. Nevertheless, this alteration itself might current a problem, because it might encourage “upcoding” of sufferers to make them seem sicker than they are surely. Alternatively, CMS might enable for threat scores of solely COVID-19 sufferers to extend and not using a restrict, adjusting for the pandemic whereas serving to to mitigate the specter of upcoding. For ACOs with small populations of sufferers which can be identified with COVID-19, these sufferers may very well be excluded from risk-scoring.
Present Superior Financial savings For ACOs To Construct Infrastructure For Telehealth And COVID Response
Many ACOs are going through fast cash circulation challenges because of the pandemic and are struggling to remain operational. We suggest incorporating a sophisticated cost model, at the very least for smaller, extra rural, extra security internet, and in any other case low-revenue ACOs, however perhaps open to all new ACOs. ACOs must use the superior cost to construct up their telehealth infrastructure (to make sure their extra susceptible sufferers profit) or for monitoring, tracing, and managing COVID-19.
This method was used within the ACO Funding Mannequin, which was profitable in supporting rural and underserved-area ACOs in succeeding in accountable care and price financial savings, however the model was discontinued. The ACO Funding Mannequin needs to be revived for COVID-19 infrastructure constructing, as it could assist reduce inequities resulting from telehealth growth. Nevertheless, Congress would want to behave to re-open a program of pay as you go medical prices.
Moreover, to help COVID administration, CMS might develop a cost to ACOs that enables them to develop the capabilities to take part in testing and tracing applications, together with sharing related knowledge with native public well being authorities for broader administration.
Guarantee ACOs Are Pretty Judged For Bettering Worth
The prices of caring for a hospitalized COVID-19 affected person are more likely to be excessive, resulting in systematically excessive expenditures for ACOs in areas with excessive charges of COVID. To deal with this, in figuring out the benchmark and in calculating shared financial savings and losses in comparison with the benchmark, the interim last rule excludes all Half A and B prices associated to COVID hospitalizations and outpatient care within the month following hospital discharge. It is a cheap method, on condition that COVID-19 is outdoors the traditional realm of well being care. It is going to assist guarantee ACOs are usually not unfairly penalized resulting from COVID, which ought to encourage continued participation in this system.
The problem is operationalization, particularly on condition that many COVID instances may not be accurately coded in claims, making it troublesome to precisely determine the bills. This may be more difficult for physician-group-led ACOs, as a separate group (the hospital) is managing and coding the inpatient care. CMS ought to additional monitor ACOs with larger COVID burden for any unintended penalties on threat adjustment and price evaluation of their affected person base.
As well as, the stop-loss provision in MSSP contracts, which excludes prices for sufferers who’ve whole expenditures at or larger than the ninety-ninth percentile of Medicare beneficiaries nationally, will mitigate among the sudden COVID-related prices (on condition that many sufferers with extreme COVID-19 instances can have very excessive utilization). CMS ought to proceed to observe how the stop-loss provision impacts any given follow, particularly if the mixture of this coverage provision and folks receiving delayed care may trigger an ACO’s expenditures to go from beneath their benchmark in 2020 to above their benchmark in 2021.
CMS can also be implementing further measures to mitigate sudden COVID-19 prices. CMS has current insurance policies for public well being emergencies that shield in opposition to losses in the course of the emergency interval, whereas sustaining value-based incentives and infrastructure. Leveraging the present excessive and uncontrollable circumstances coverage, CMS has famous shared losses might be mitigated by the size of the general public well being emergency. With the probability that the general public well being emergency, declared in January, might final the remainder of the yr, there’s a robust risk that shared losses can be waived completely this yr. Nevertheless, ACOs might nonetheless obtain shared financial savings in the event that they handle care effectively throughout this time (in comparison with their regional and nationwide friends), which ought to encourage larger inhabitants well being administration. Retaining shared financial savings funds is most vital to small or physician-led ACOs, as they extra regularly use (and due to this fact rely extra regularly on) value-based funds.
Handle Challenges In Assessing High quality Care throughout Pandemic
COVID-19 will doubtless have an effect on how ACOs carry out on sure high quality measures, which CMS didn’t talk about within the interim last rule, regardless that these measures have an effect on funds. There may be some challenges in utilizing present high quality measures given the robust drop in utilization. For example, colonoscopy and mammography charges are more likely to be decrease this yr with at the very least eight weeks of non-urgent diagnostics cancelled. This may be a case for ACOs to look at new methods to satisfy high quality measure requirements, reminiscent of utilizing at-home exams for colonoscopy or utilizing cell mammography models to help with bodily distancing.
Nevertheless, utilizing alternative routes to satisfy high quality measure targets may not be doable or acceptable for all measures. We suggest CMS take a measure-by-measure evaluation for figuring out options. Another choice can be to make 2020 a “pay-for-reporting” yr for high quality measures, to keep away from penalizing ACOs for deferring non-urgent care. CMS might additionally take into account including a “quality boost” for ACOs that do effectively in managing COVID, together with testing and tracing. This might probably be tied to significant use of knowledge for COVID surveillance.
The COVID-19 pandemic has highlighted the fragility of the FFS cost system, as many practices are going through unsustainable income declines. Organizations taking part in APMs (together with ACOs) have been in a position to each take care of sufferers extra successfully in the course of the pandemic and higher face up to its monetary impacts, as they’ve decoupled value from quantity. Whereas some adjustments are wanted to make sure ACOs are usually not unfairly penalized because of the pandemic, CMS needs to be selling larger supplier participation in APMs, not limiting their choices. The clear precedence is making certain high-quality care methods for the pandemic and past, whereas serving to organizations get well from present losses—all of which might be supported via a larger push away from FFS funds.