The AHA is pleased that the final rule on the Medicare Shared Savings Program (MSSP) gives participants in Track 1 – the most basic version of a Medicare accountable care organization (ACO) – the option to renew their agreements for another three years. But the association said the rule could have done more to restructure the risk-reward balances in a way that would encourage greater hospital participation. 

The rule, released June 4 by the Centers for Medicare & Medicaid Services (CMS), “makes some positive changes and provides additional flexibility to the MSSP,” said Linda Fishman, the AHA’s senior vice president of public policy analysis and development. “However, the program needs additional reforms to make it more attractive to new participants and existing ACOs.”

Under the final rule, participants can continue to stay in Track 1, which doesn’t involve downside risk and is the ACO model for about 99% of participants. The rule maintains participants’ level of eligible shared savings at 50% – as the AHA had urged the agency in comments on the rule proposed in December. The proposed rule called for lowering the level to 40%.

Among other provisions, the rule changes the methodology for assigning beneficiaries to ACOs, creates a third track for MSSP participation, and provides additional data to help ACOs better manage care.

More than 400 organizations participate in MSSP and provide care to some 7.2 million Medicare enrollees. The program ties financial incentives to the organization's performance on quality targets. The final MSSP rule would affect new ACOs entering the program in January 2016 as well as MSSP ACOs renewing their agreements for another three-year performance period.

The program’s Track 2 model includes a risk of losses in exchange for a greater share of the savings. The new Track 3 is a two-sided shared savings and losses model that requires greater performance risk in exchange for greater potential savings. CMS said upside and downside risk for this model will be 75%, meaning an ACO's bonus or penalty would be up to 75% of its savings or loss.

The AHA is “pleased that CMS will allow the vast majority of early ACOs to continue to participate another three years at current risk levels,” said Fishman. She also noted that the rule will make it easier for certain ACOs to share in the savings they generate.

But she said more could be done to remove some of the barriers to providing the kind of care sought by CMS under the Track 1 model. CMS agreed to waive the three-day inpatient stay minimum for a patient to qualify for skilled nursing facility care, but did so only for Track 3.

Still, Fishman said “hospitals are enthusiastic about the program as one pathway to advance their ongoing efforts to transform care delivery as a way to improve patient care and reduce costs.”

The AHA June 5 sent its members a Special Bulletin with more details on the rule.