![新的Cms规则为医疗保险Acos网络带来了巨大变化](/Areas/CMS/assets/img/blank.gif)
在2018年的最后几天, CMS released its 2019 final rule for the Medicare Shared Savings Program (MSSP), thereby finalizing several significant program changes that CMS had previously proposed in August 2018. These changes were announced unexpectedly and came as a surprise to many organizations that were anxiously awaiting CMS’s overdue release of guidance for the 2019 MSSP application cycle. 随着这些新变化, CMS and the Trump administration are signaling their resolve in accelerating the transition to value-based reimbursement.
从CMS更肌肉的立场
The release of the MSSP 2019 proposed rule in August was accompanied by some uncharacteristically frank commentary from government officials regarding the program’s perceived issues and their desire to fix it. As HHS secretary Alex Azar put it, “having more Accountable Care Organizations take on 真正的风险, 同时为他们提供节省所需的灵活性, is an important step forward in how Medicare pays for value” (emphasis ours). CMS管理员Seema Verma可能更直接地说, “Medicare cannot afford to support programs with weak incentives that do not deliver value,” and “Medicare ACOs do not currently face any financial consequences when costs go up, 这种情况必须改变.”
The commentary within the final rule echoes these sentiments by pointing out that one-sided (i.e., upside-only) ACOs actually have increased Medicare spending relative to their benchmarks and that “while we understand that systems need time to adjust, Medicare cannot afford to continue with models that are not producing desired results.“值得注意的是, CMS’s commentary also includes multiple mentions of the need to protect the Medicare trust funds, 哪一个, 根据目前的估计, 还有不到十年就会干涸吗.
在这样的背景下, it is easy to understand the rationale for the changes that CMS has made to the program.
ACOs的主要变化要点
因为最终规定是在12月底发布的, CMS要到7月1日才会实施这些变更, 2019, 哪一个 will be the effective date of the next round of contracts between ACOs and CMS. 从那时起, 标准的ACO合同期限将改为五年, 而不是传统的三年. (适用于7月1日起的机构, the first contract will be for five and a half years to get them back on the calendar year cycle.这个较长的合同期限是为了促进阶段性的发展, 强制过渡到更高级别的风险. 要做到这一点, 现有的四条轨道(1, 1+, 2, 3)分为两个轨道(BASIC和ENHANCED). The BASIC track allows participants to phase in additional risk through a “glide path” that involves beginning with a one-sided risk model for the first two years (or two and a half years for ACOs entering the BASIC track with an agreement period beginning on July 1). 在那之后, ACOs on this track will transition to a two-sided risk model for the remaining three years of the five-year contract. ACOs可以选择更快地通过这五个关卡, 以更快的速度承担额外的风险, 但他们不能选择较慢的进程. Further, ACOs previously participating in Track 1 are only allowed one year in a one-sided model.
鉴于ACOs在转向双边风险模型方面的历史犹豫, these developments might appear at first to be a tightening of the screws by CMS. 然而, CMS已经完成了一些额外的和, 在某些情况下, innovative changes that should make it easier for ACOs to be successful in managing two-sided risk. 例如, the cost-benchmarking methodology in an ACO’s first performance period will consider regional cost factors rather than simply the ACO providers’ historical cost experience. This should benefit ACOs that provide care more cost-effectively than others in their market. 也, beneficiary assignment rules have changed to allow more flexibility in defining patient populations with 哪一个 the ACO can succeed. 最后, the new rule introduces innovations such as beneficiary incentives for qualifying services, 扩大远程保健bet8娱乐的支付, 和其他人.
ACO或不ACO?
Organizations interested in forming and/or participating in an ACO face a complex decision involving the ever-present uncertainty regarding healthcare at the federal level, 与其他医疗保险计划相比,MSSP的特点, and their own internal capabilities for management under value-based reimbursement.
Although predicting the future of health policy is notoriously difficult, we do know some things and can make informed assumptions about others:
- We know that the Trump administration is serious about getting healthcare costs under control and is not shy about exercising executive privilege, 即使面对政治上的反对.
- 而2019年规则的变化预计将使成本降低2美元.90亿美元, this amount is minuscule in comparison to the level of reductions needed to make Medicare sustainable.
- 这2美元的大部分.9 billion savings projection is not attained through decreased utilization but through reduced “ACO net earnings,,这可能意味着在双边模式下的处罚.
- 民主党现在牢牢控制着众议院, 废除《bet8娱乐》的可能性几乎为零, 就此而言, any other significant healthcare legislation—within the next two years at least.
- 至于最近德克萨斯州法院对个人强制医保的裁决, the appeals process will play out over an extended period; even if the ruling holds, 它可能会也可能不会最终影响现有的医疗保险计划.
- All evidence indicates that CMS is unlikely to develop and implement new programs through the 创新 Center.
结果是, healthcare providers can expect to take on ever-greater levels of risk at an accelerated pace, and CMS’s need to reduce costs will likely drive further refinements to these models. 好消息是, 考虑到政治现实, we don’t anticipate new models cut from whole cloth anytime soon; the tools available to CMS for the foreseeable future are likely to be the same ones in place today. From that perspective, the next few years may be more predictable than the past few years have been. The upshot of all this is that it is now more important than ever for providers to understand the models under 哪一个 they will participate in Medicare, 哪种模式对他们来说最有意义, 以及如何在这些模式中取得成功.
2019年1月21日发布