The Centers for Medicare and Medicaid Services (CMS) released a sweeping draft regulation in August 2018 which, if enacted, will significantly change the Medicare Shared Savings Program (MSSP). The proposed regulation, called Pathways to Success, accelerates the path for accountable care organizations (ACOs) to assume downside risk. Along with a faster path to assuming downside risk, key provisions allow certain provider-led ACOs to participate with reduced financial risk and lengthen the agreement periods to five years, without benchmark rebasing for those five years. CMS has also proposed minor methodology and operational changes for the program.

For new MSSP entrants or those renewing an agreement, there are two tracks offered. The BASIC track includes features that allow ACOs to ease into risk and make adjustments for low revenue or inexperienced ACOs to limit their total loss exposure. The Enhanced track is essentially the same as the current Track 3 with greater downside risk. The proposed rule contains interesting new options for choice of attribution and expanded access to and definitions of Skilled Nursing Facility (SNF) waivers, telehealth services, and patient incentives.

In moving to shared risk, ACOs are fundamentally taking on a measure of insurance risk. It is essential to understand the program rules and dig into the rich claims data provided for program participants.

In this series of papers, Milliman consultants examine the changes to the MSSP program and provide comprehensive information to help interpret these changes, exploring even the most detailed nuances and implications.

“Pathways to Success” MSSP proposed regulation: Summary white paper

By Colleen Norris, Cory Gusland, Charlie Mills and Hugh Larson | 20 August 2018

This paper provides a summary of the Centers for Medicare and Medicaid Services’ sweeping proposed regulations that will significantly change the Medicare Shared Savings Program.

“Pathways to Success” MSSP proposed rule: Financial benchmark

By Jill S. Herbold, Cory Gusland and Charlie Mills | 28 August 2018

This paper discusses “Pathways to Success” and the important implications in store for Medicare accountable care organizations.

“Pathways to Success” MSSP proposed rule: Beneficiary assignment

By Colleen Norris, Jason McEwen and Jonah Broulette | 7 September 2018

This paper explores the differences between the two beneficiary assignment methods, prospective or retrospective, and considerations for accountable care organizations as they evaluate their options.

"Pathways to Success" MSSP proposed rule: Beneficiary incentive program

By Carol Bazell, Susan Philip and Laurie Lingefelt | 27 September 2018

This paper explores the beneficiary incentive program proposed in the Medicare Shared Savings Program.

"Pathways to Success" MSSP proposed rule: Winners and losers

By Anders Larson and Cory Gusland | 3 October 2018

This paper describes how the impact of the rule change will vary by ACO depending on its current situation and unique characteristics and examines the rule from the perspective of different ACO situations.

"Pathways to Success" MSSP proposed rule: Assignment changes to identification of E&M Services in skilled nursing facilities

By Anders Larson and Jill S. Herbold | 19 October 2018

This paper discusses the current and proposed rules related to evaluation and management services in the Medicare Shared Savings Program.

“Pathways to Success” MSSP proposed rule: Integrity

By Jason Karcher and Brian Sweatman | 5 November 2018

This paper discusses ways in which accountable care organizations have been identified by the Centers for Medicare and Medicaid Services (CMS) as weakening integrity and how CMS is proposing to address concerns.

“Pathways to Success” MSSP final rule: Faster movement to downside risk increases focus on reducing population costs

By Kathryn V. Fitch, Adam Laurin and Michele M. Berrios | 4 January 2019

Under the new Medicare Shared Savings Program’s new rule, there will be a more urgent need for accountable care organizations to reduce population costs.

“Pathways to Success” MSSP final rule: Key revisions to the proposed rule

By Noah Champagne, Charlie Mills and Jason Karcher | 7 January 2019

This paper summarizes the key provisions of the final rule for the 2019 Medicare Shared Savings Program and highlights differences from the Centers for Medicare and Medicaid Services’s August proposal.

"Pathways to Success" MSSP final rule: Winners and losers

By Anders Larson, Cory Gusland | 14 February 2019

This paper examines the Medicare Shared Savings Program’s (MSSP) final rule from the perspective of different accountable care organization (ACO) situations to help readers understand how the MSSP rule might affect different ACOs.

“Pathways to Success” MSSP final rule: Financial benchmark

By Jill S. Herbold, Cory Gusland, Charlie Mills and Emma J. Kramer | 22 February 2019

This paper discusses the changes to the financial benchmark methodology that measures the gross savings or losses of an accountable care organization under the Medicare Shared Savings Program.