Unveiling the Mysteries of US Healthcare – Medicare Shared Savings Program (MSSP)

If you are associated with the US healthcare industry in any way, you must have already tried to put your brain around the Medicare Shared Savings Program (MSSP). And I can totally understand that it must be taking its toll on you already…. But have faith; the MSSP might be the biggest thing that has happened to US healthcare ever since the introduction of Medicare and Medicaid program in the 1960s. And if you are planning to turn a blind eye towards this revolution in the US healthcare, you might just end up facing more challenges later than you are required to face now.

There is no way that I can put everything that is in the 100s of pages of legislature crafted for the MSSP in this blog. However, I would try to build a basic idea around what the MSSP is and why it has been implemented by the Federal government.

The Program

MSSP or the Medicare Shared Savings Program was established by the Centers for Medicare and Medicaid Services (CMS) as required by the Patient Protection and Affordable Care Act or Obamacare which was enacted on March 23^rd 2010. This program has been introduced to promote the concept of Managed Care in the United States.

The MSSP intends to promote the Fee for Service providers of Medicare to provide coordinated care to specific groups of Medicare Beneficiaries by the formation of ACOs (Accountable Care Organization). This would help in reducing the quantity of unnecessary healthcare procedures performed by the providers which do not have any impact (or sometimes even have a negative impact) on the clinical outcome of the patients. This in turn would reduce the per capita cost of care and result in reduced healthcare funding.

To promote the providers to do so, the program proposes to share a significant amount of these savings with the providers. But the program also tries to ensure that the quality of care is not compromised in an effort to increase the amount of savings. For this the MSSP obtains certain quality measures from the ACOs to calculate their overall performance and share the savings accordingly.

Major Provisions

Following is a list of some of the major provisions in the program,

• Individual Providers and Hospitals need to come together to form a legal entity called an ACO. All the providers in the ACO should be eligible and willing to participate in the MSSP
• The ACO needs to take part in the program by signing an agreement to participate in the program for a period of three years
• The beneficiaries will be allocated to an ACO through the Primary Care Providers (PCPs) participating in the ACO
• The Providers need to manage the overall health of their allocated beneficiaries by emphasizing on preventive medicine
• The participants in the ACO need to put a combined effort to control healthcare costs and achieve significant savings based on the benchmarks set by CMS
• The ACO also needs to focus on the quality of healthcare provided as the performance of the ACO will be judged on certain clinical quality measures that are required to be reported to the CMS
• The Medicare beneficiaries should be given online access to their healthcare data generated within the ACO

Quality Reporting

The CMS calculates the qualitative performance of the ACO by the use of clinical quality measures. A total of 33 measures will be used by CMS for calculating the quality performance. These 33 measures can be divided into 4 domains.

1. Patient/caregiver experience (7 measures)
2. Care coordination/patient safety (6 measures)
3. Preventive health (8 measures)
4. At-risk population:
   • Diabetes (6 measures)
   • Hypertension (1 measure)
   • Ischemic vascular disease (2 measures)
   • Heart failure (1 measure)
   • Coronary artery disease (CAD) (2 measures)

The CMS derives some of the quality measures from its own data sources such as Claims Data and EHR Incentive Program Data. Others are required to be reported by the ACO to CMS via PQRS GPRO Web interface for ACOs and a CAHPS certified survey vendor.

Calculation of Savings

The participating ACOs need to achieve significant savings in the overall healthcare cost based on the benchmarks set by CMS and also successfully report clinical quality measures while performing as per the prescribed quality standards.

The benchmarks are calculated based upon various criteria like the historical expenditure, the national average growth rate of the US, etc. In the first year of participation, quality performance is not taken into consideration but reporting the measures is required for becoming eligible for the shared savings.

If both of these goals are achieved Medicare pays a significant amount of the savings to the ACO. This amount is then distributed amongst the various participating providers in the ACO based on the defined rules. CMS shares up to 60 % of its savings with the MSSP participants based on the risk shared. There is also a variant of the shared savings payment model known as the Pioneer ACO which is a population based payment model and designed to work in coordination with private payers.

Though this program has been regulated for only Medicare beneficiaries, it is quickly gaining popularity and being adopted by private payers as well. And this is because they have realized that this model of care will not only improve the quality of care provided but also bring down the overall healthcare cost which will be a win-win situation for everyone.

Although this is only the tip of the iceberg, I hope that you have developed a good understanding of what the MSSP is about and why it has been implemented. For more ‘US Healthcare’ mysteries that I have to unveil, stay tuned for my next blog on Meaningful Use Stage 2.