Tag: cms

ACCESS Might Be InACCESSible

Posted on by Jason Barry

The wait for CMS’ new ACCESS model payment rates is finally over, but the debate over whether or not they’re financially viable is just getting started.

Advancing Chronic Care with Effective, Scalable Solutions. ACCESS was designed to move more Medicare beneficiaries away from fee-for-service toward outcomes-driven models.

  • The program’s core mechanism for accomplishing that is Outcome-Aligned Payments (OAP), a per-beneficiary annual allowed amount to cover integrated care management for chronic conditions.
  • The end goal is to get more tech-forward companies to lean in on Medicare by rewarding them for using technology to improve patient outcomes.

That goal might be hard to reach. Here are the annual OAPs by clinical track and care period:

  • Early Cardio-Kidney-Metabolic (eCKM) – $360 initial, $180 follow-on
  • Cardio-Kidney-Metabolic (CKM) – $420 initial, $210 follow-on
  • Musculoskeletal (MSK) – $180 initial, N/A follow-on
  • Behavioral Health (BH) – $180 initial, $90 follow-on

Those numbers present some real challenges. They’re considerably lower than expected, and many of the companies that had already announced plans to participate are now being forced to reevaluate the decision.

  • For the sake of comparison, Medicare’s average annual Part B spending for a diabetic patient is around $700 under fee-for-service.
  • Asking providers to deliver comprehensive, tech-enabled care for half of that is a tall order, especially for services-heavy companies with humans in the loop.
  • Companies with an AI-first approach and an established patient pipeline might perform better, but even then the rates are so low that they’ll likely do little to motivate new entrants to Medicare given the infrastructure needed to comply with the program and achieve the desired outcomes.

The Takeaway

CMS has made it clear that it’s going to start taking bigger steps to control costs, but it also has to find rates that actually encourage companies to participate. Striking that balance is an unenviable task, but the initial consensus seems to be that ACCESS missed the mark.

CMS Reports Record MSSP Performance in 2024

Posted on by Jason Barry

CMS just dropped its 2024 performance data for the Medicare Shared Savings Program, and the debate over the program’s true effectiveness rages on despite another record year. 

MSSP saved Medicare $2.4B in 2024, the eighth consecutive year of savings and the highest total since the program’s inception in 2012.

  • The program generates savings by working with accountable care organizations to cut down on avoidable utilization, eliminate duplicative care, and minimize costly medical errors.
  • The ACOs that effectively improve care quality and reduce total spend share in the success, and last year saw 75% of participating ACOs earn $4.1B in performance incentives, a new all-time-high.

Accountable care delivers. MSSP ACOs lifted hypertension control rates to 79.5% in 2024 (up from 77.8% in 2023), while trimming the share of patients with poor hemoglobin A1c control to 9.4% (from 9.8%).

  • Low revenue ACOs (typically physician-led) continue to outperform high revenue ACOs (typically hospital-led), generating $316 in net per capita savings (vs. $175).
  • Most ACOs also performed better than comparable physician groups on quality measures, such as screening for depression and creating follow-up plans (53.5% vs. 44.4%).

There’s always a catch. Although at first glance 2024 was one of MSSP’s best years to-date, it’s worth noting that total Medicare spending also reached a staggering $847B.

  • That means that MSSP, the crown jewel of CMS value-based care programs that includes 476 ACOs equipped with some of the best care delivery tools in the industry, delivered an overall savings of just 0.28%.
  • $2.4B is nothing to scoff at, and the program is moving the needle, but it’s nowhere near fast enough to keep pace with Medicare’s runaway growth.

The Takeaway

MSSP had a great 2024 by almost every metric, and its ACOs are the tip of the spear for CMS’s push toward value-based care. That said, it’s a long journey to lower overall Medicare spending even with $2.4B steps, and there’s still plenty of work to be done to help get there faster.

Make Health Tech Great Again

Posted on by Jason Barry

CMS just wrapped its Make Health Tech Great Again event at the White House, and it unveiled an ambitious new strategy to modernize how healthcare data is exchanged.

This time is different. We’ve heard similar promises before, but the administration plans to “stop theoretical debates and start delivering real results” by taking a two-pronged approach.

  • The first priority is establishing a CMS Interoperability Framework to enable seamless information exchange between patients and providers. 
  • The second step is building a Health Tech Ecosystem to improve access to personalized tools so that patients have the resources they need to make better health decisions.  

The CMS Interoperability Framework includes voluntary criteria for data sharing across different network types – health information exchanges, EHRs, and tech platforms.

  • The blueprint covers everything from patient and provider access to transparency and security, complete with implementation guidelines co-developed with the early adopters. It’s completely aligned with TEFCA, which CMS is still participating in.
  • Over 20 networks pledged to meet the criteria to become CMS Aligned Networks, such as delivering data through FHIR APIs, updating the national provider directory, and providing metrics on network queries for patient records.

The Health Tech Ecosystem is a “standards-based digital health environment” that will integrate apps, EHRs, and care delivery organizations with the new CMS Aligned Networks. 

  • The ecosystem will leverage these integrations to develop new solutions for: (1) managing diabetes and obesity, (2) conversational AI to help check symptoms and navigate care, (3) “killing the clipboard” by replacing paper forms with digital solutions.
  • Over 30 companies and 11 major health systems signed on to “deliver results for the American people” by the first quarter of 2026, and the full roster includes some of the biggest names in healthcare.

The Takeaway

We apparently won’t have to wait long for the CMS Interoperability Framework and Health Tech Ecosystem to deliver results, although what those deliverables will look like remains to be seen.

CMS Reports Record Performance for MSSP

Posted on by Jason Barry

CMS just released the Medicare Shared Savings Program results for 2022, and the report managed to drum up some serious debate on the effectiveness of MSSP despite last year’s record performance. 

MSSP saved Medicare $1.8B in 2022, marking the sixth consecutive year of savings and the second-highest total since the program launched in 2012.

  • The program generates savings by working with accountable care organizations, or groups of providers who collaborate to cut down on avoidable utilization, duplicative care, and medical errors.
  • The ACOs that effectively improve care quality and reduce total spend are then able to share in that success, and 63% of participating ACOs were compensated in 2022.

Standout performers included Aledade (four of the top ten ACOs for overall savings rates) and Privia (delivered expenditures 8% lower than the median MSSP ACO), although results were mixed for other high profile participants like CVS.

  • CMS called out the fact that low-revenue ACOs comprised mostly of primary care physicians generated $294 per capita in net savings (vs. $140 per high-revenue ACO), underscoring the importance of primary care to the overall program. 

Although at first glance those numbers make 2022 one of MSSP’s best years to-date, it’s worth noting that the total cost of Medicare over that time frame was a mammoth $747B.

  • That means that MSSP, the crown jewel of CMS value-based care programs that includes 482 ACOs equipped with some of the best care delivery tools in the industry, delivered an overall savings of just 0.24%.
  • That’s not to say that $1.8B is anything to scoff at, but it highlights the sheer size of the task at hand, and CMS devoted a healthy portion of the press release to proposed MSSP updates that would include more people who receive care from NPs / PAs and encourage ACOs to care for more medically complex beneficiaries. 

The Takeaway

MSSP had a great 2022 by almost every metric, and the ACOs participating in the program are the tip of the spear for improving the country’s fractured health system. That said, it’s a long journey to lower overall costs even with $1.8B steps, and there’s still plenty of work to be done to help get there faster.

Get the top digital health stories right in your inbox