Dr Rob Fields Highlights Areas for Continued Innovation With ACOs

There remain issues with benchmarking, attribution, and risk adjustment that CMS needs to address with accountable care organizations (ACOs), said Rob Fields, MD, assistant profession, family medicine and community health, Icahn School of Medicine at Mount Sinai, and senior vice president, chief medical officer, population health at Mount Sinai Health System.

What are some areas for continued improvement in Medicare Shared Savings Program that CMS has not addressed yet?
I think that’s a difficult question. They’ve addressed a lot of the things in part. So, I think there are several major buckets, I think, where systems and other ACOs have concerns. One is around benchmarking. The way that CMS attributes the target price essentially for patients has been challenging and hard to predict. It is improving: things like regional benchmarking, for the most part, is a step in the right direction for most systems, but not across the board. But I think what needs to improve is the predictability. We see pretty significant swings even within the same performance year from baseline, historical benchmarks, to final, reconciled benchmarks. And I think that’s a challenge, especially when you’re talking about risk. If we’re seeing swings of as much as 10% in how the benchmark goes, that’s really difficult to predict. You could be tracking great all year, and then end up upside down in the end in a way that wasn’t predictable. So, that’s a problem and it doesn’t exist in Medicare Advantage, but it absolutely exists in these models.

I think the other piece is attribution still can be challenging. And I don’t know if there’s a perfect solution for that, whether it’s retrospective or prospective and there are models that try to address both. There are ways of perhaps reconciling attribution based on where patients are actually seen and things like that. But I think there needs to be continued work on attribution, as well.

And I think the last one, which is as important as the benchmarking piece, is ability to risk adjust throughout the performance year would be particularly helpful as the population changes. There is certainly significant churn in membership because of attribution. And not being able to adapt the risk adjustment to the new patients that are coming on is perhaps a problem.

What additional innovations would you like to see coming out of CMS?
I would really be interested in things coming out of CMMI [Center for Medicare and Medicaid Innovation] that start to look at how do we pay or how do we finance the social determinants and other nonhealthcare-related services that we all deal with. We are talking about it here at the conference this fall, many sessions discussing how we handle social determinants and how we finance that. And having models that more easily tie the delivery and coordination of those services, which is very much a part of this work, finding a way of connecting that to the financial model, I think, would be an interesting thing to try to work on. But that’s likely more of a CMMI innovation process rather than a true MSSP process.
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