The Centers for Medicare and Medicaid (CMS) announced on August 24 that the Medicare Shared Savings Program (the MSSP) had the second-highest annual savings accrued for Medicare since the program’s initial launch in 2012 (2022 MSSP Report). That marks 2022 as the sixth consecutive year that the MSSP produced net savings and high-quality performance results, promoting the MSSP's overarching goals of controlling costs and promoting clinical excellence. 

The MSSP offers a collaborative, value-based opportunity for professionals and facilities to partner in accountable care organizations (ACO) and demonstrates that cost control can coincide with high-quality patient care. The MSSP aligns participant, enrollee, and payor incentives to improve health outcomes by promoting higher quality, coordinated care, while simultaneously decreasing unnecessary medical expenditures. The MSSP is expanding in both participants and enrollees, and CMS has vast plans for continued growth. In the 2022 MSSP Report, as of January 2023, the MSSP includes over 573,000 participating clinicians who provide care to nearly 11 million people on Medicare. While CMS has set a goal to have 100 percent of Medicare enrollees become part of an accountable care relationship by 2030, the 11 million enrolled today is far from the 63.8 million total Medicare enrollees, as reported by CMS in 2021. The MSSP appears to be on the right track in terms of consistent growth and achieved shared savings, but work remains to be accomplished by ACOs to continue to reach the ever-growing Medicare population, especially in rural and underserved locations. 

A noteworthy 2022 MSSP Report data point was the significantly higher per capita savings amounts for ACOs with primary care clinicians serving small hospitals and rural populations. According to CMS, “low-revenue” ACOs tend to be made up of physicians and may include a small hospital or serve rural areas. While these ACOs may be considered “low-revenue” they are far from “low-savings” on a per capita basis, especially when primary care is involved.

“With $228 per capita in net savings, low-revenue ACOs led high-revenue ACOs, who had $140 per capita net savings, and low-revenue ACOs comprised of 75% primary care clinicians or more saw $294 per capita in net savings, more than twice as much.”

This data is interesting, as it reveals both the importance of the MSSP reaching underserved and rural populations and prioritizing primary care within the MSSP. [1]  

Before the release of the 2022 MSSP Report, CMS had previously proposed changes to increase participation in the MSSP at all levels, but particularly for underserved and rural areas. Among others, the proposed changes for underserved and rural populations include: 

1. Moving ACOs “toward a digital measurement of quality” by instituting a new Medicare Clinical Quality Measure (Medicare CQM) collection type under the Alternative Payment Model Performance Pathway. Further, CMS proposed that “ACOs that report Medicare CQMs would be eligible for the health equity adjustment to their quality performance category score when calculating shared savings.” By adding a health equity adjustment to an ACO’s quality performance category score CMS facilitates recognition of an ACO’s provision of high-quality care to underserved populations.
2. Modifying the “calculation of assigned beneficiaries dually eligible for Medicare and Medicaid, and the calculation of the proportion of assigned beneficiaries enrolled in the Medicare Part D low-income subsidy (LIS), to use the number of beneficiaries, rather than person years, for calculating the proportion of the ACO’s assigned beneficiaries who are enrolled in LIS or who are dually eligible...” With this modification, CMS aims to fortify incentives for ACOs to help facilitate LIS enrollment for beneficiaries who meet eligibility criteria and to reach the underserved or dually eligible who tend to fall into the LIS population.
3. Updating the definition of assignable beneficiary to account for beneficiaries who receive primary care from advanced practice providers during the 12-month assignment window and one primary care service from a physician in the preceding 12 months. CMS also proposed adjusting the assignment methodology by expanding the window for assignment which “would result in a greater number of…beneficiaries who tend to come from underserved populations.” Ultimately, both changes are intended to increase access to ACOs for underserved populations because they impact downstream aspects of the MSSP that rely on these metrics to define the ACO’s regional service area.

The 2022 MSSP Report cohesively supports CMS's efforts to target specific populations and primary care as places for improvement to increase accessibility and, ultimately, increase the quality of care received through the MSSP. Meaning, CMS is optimistically on the right track to both increase MSSP participation to move closer to meeting its 2030 goal, and reach populations that serve to benefit, potentially, the most from such value-based arrangements. 

There is a 60-day public comment period on the proposed rule set to close on September 11, 2023, to submit comments, questions, and suggestions for CMS consideration before finalizing the proposed rule. Comments can be submitted at Regulations.gov.

[1] See also “CMS Initiative to Enhance Primary Care Services,” Tracie Bedeaux (July 14, 2023) for more information on ways that CMS’s Innovation Center is promoting primary care through a new voluntary primary care model titled, “Making Care Primary.”