By Daniel Juberg, Senior Consultant, The Camden Group
With the recent Centers for Medicare and Medicaid Services (“CMS”) announcement of the 2016 Medicare Shared Savings Program (“MSSP”) application cycle, many provider executives find themselves evaluating if the time is right for their organization to apply. CMS allows organizations only one opportunity per year to apply. The May 29, 2015 deadline to submit a non-binding Notice of Intent to Apply is rapidly approaching. Can your organization wait until 2017? Here are some considerations for why the Medicare Shared Savings Program could be the right move for your organization now.
Control Your Competitive Landscape
Take a moment to evaluate your competitors. Who are your competitors and what are they doing? This includes traditional competitors, like hospitals, health systems, and physician groups, as well as other non-conventional competitors who provide ancillary healthcare services, such as pharmacies and retail clinics. Are they forming accountable care organizations (“ACOs”) or similar, value-based organizations? Are they considering or even already participating in the MSSP? If so, their participation could preclude or delay the success of yours in the future. Many executives are using the MSSP as a defensive maneuver to build or protect market share. How? ACOs must have a minimum patient assignment of 5,000 Medicare lives to be eligible to participate in the MSSP. These lives are attributed, predominantly through participating primary care physicians, to the ACO through the group/physician Tax Identification Numbers (“TINs”) that sign participant agreements with them. These TINs can only participate in one ACO in the MSSP. This assignment exclusivity is a defined population play for your organization. Through the MSSP, you can build and/or solidify your primary care base and the patients for whom they care. Even if your competitors are not in the MSSP, this is the opportunity to lead your market, align your physician partners, and solidify your position in the Medicare landscape.
Consider the current payer activity in your market. Are payers currently approaching you or your competitors with value-based, shared savings contracts? Have you considered the infrastructure and care coordination redesign that such arrangements might require? Commercial and government payers are already moving towards value-based payment, so the urgency to transform care delivery models for success in value-based payment models is real. The MSSP can be used as the impetus for change, help you stay ahead of the game, and prepare you for future success under value-based payment.
Prepare for the Triple AimTM
Consider the opportunity to coordinate care and improve quality - with little financial risk. The MSSP allows you to build the infrastructure framework – a coordinated care network that spans the continuum – for the ACO without downside financial risk for the first three years. It provides a simple platform to develop a mutually beneficial, ever-evolving financial funds flow to encourage and support clinical behavior change along the care spectrum. Through the physician-led organizational structure, clinicians are engaged in care model redesign that maintains the patient at the center of their care. Organizational leadership and participants work together to develop quality, patient satisfaction, and performance metrics for transparent reporting and subsequent measurement, which encourages EMR use and physician connectivity and participation. Through this dedication to value-based and coordinated care, all participants are contributing to the achievement of better quality, cost savings, and healthy patients – which will be rewarded with upside incentives in MSSP and commercial ACO initiatives. Gaining this experience with little risk will enable the organization to begin the “rewiring” process to allow participation in other higher risk (and reward) models that may be offered by payers in the future.
Evaluate synergies to better manage care for other target populations. Organizations can also use shared resources developed for the MSSP to incorporate their employee population within the ACO infrastructure to pilot the care coordination efforts and a similar shared savings program. Additionally, some are finding system-wide, cross- payer synergies that benefit their bottom line and keep patients in their care network. For example, some organizations are using their Call Centers or “Hotlines” to not only answer questions about the ACO as required by CMS, but to provide 24/7 physician access, encouraging patients to seek care within their network or sphere of influence while reducing unnecessary emergency department admissions through the use of an urgent care facility.
Evaluate Potential for Profitability Under MSSP
Assess the impact on revenue against your ability to manage costs and achieve efficiencies. ACOs in the MSSP are absolved from downside financial risk for the first three years of the Track 1 program as they work to recruit, refine, and strengthen their clinically integrated networks. But, can you be “profitable” under MSSP? Possibly. In a fee-for-service environment, savings can be generated as a result of the ACO’s cross-continuum care delivery model which streamlines workflow and transitions of care to reduce waste and inefficiencies. This often begins with the reduction of costly acute care hospital-based utilization. Consider, particularly if you are a hospital, how much you can reduce inpatient utilization under the MSSP and whether you can offset the loss of inpatient opportunity with additional patient throughput and capacity across the system. Also, will you be able to grow market share and align MSSP participation with ongoing expense reduction and operational improvement efforts, such as through Lean and Six Sigma? For those with experience in medical management and managed care, you may be particularly well positioned for MSSP. Further, as the federal budget gets squeezed, obtaining any upside in Medicare payment will be important as traditional fee-for- service payments get cut.
Success in the MSSP relies on the ability of an organization to appropriately manage the care, utilization, and cost of a defined population while continually improving quality and clinical outcomes. It also requires full commitment and a clearly defined vision; half-hearted efforts will fail and can be costly both organizationally and financially. Participating in the MSSP will test, facilitate, and/or impel your organization’s path to value-based care. Dipping your toes in the MSSP water may not be the risky proposition - the real risk might lie in not acting now.