ACA repeal could make ACOs, MACRA, Medicare Shared Savings and CMS CMMI more complicated, experts say
With Donald Trump's election comes a tide of questions about what shape his healthcare plans will take. He has long sworn to repeal and replace the Affordable Care Act, and the proposal floated on his presidential transition website also hints at other aspects of his plans.
Among the key issues that healthcare executives are keeping an eye on are MACRA, the Centers for Medicare and Medicaid Innovation, otherwise known as CMMI, Medicare Shared Savings Program, and Accountable Care Organizations.
While some of MACRA is tied up in the ACA, experts said for the most part MACRA is safe, and will move forward largely untouched.
Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said they are advising members to simply continue preparation for MACRA implementation.
"We don't see that that is going to be repealed. It was bipartisan, nearly a unanimous vote."
Christopher Kerns, managing director at The Advisory Board, also said MACRA is safe.
"MACRA is not in trouble, but mechanisms by which they control spending is what could change."
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Kerns said there might be a shift away from accountable care organizations as a principal driver of controlling spending, and more toward bundled payments or price control, cuts, or other forms of utilization control in the form of reduction in reimbursement for different kinds of services.
"So far the ACO results that have been published have been tepid at best. There is not a lot of evidence that they have saved CMS a lot of money. It may be that congress does not have the patience for it," Kerns said.
Much of the conversation about what could change revolves around CMMI, which is responsible for testing innovative payment and care delivery models, and whether it remains intact, undergoes some changes, or is scrapped outright along with the ACA remains to be seen.
When it comes to many CMMI programs, Kerns said it's possible Congress may want to assert more control, and not provide them as much authority to make payment changes. Instead, they may opt for more mechanisms related to payment cuts.
He said the greatest criticism of CMMI is that the changes they make are not subject to congressional approval, so for what is one of the largest spending programs on earth, Medicare, Congress doesn't get much say in how payment is going to be reformed going forward. But CMMI is part of the ACA, so if they repeal the law, CMMI goes with it.
On the other hand, CMMI does provide the administration powerful tools to change payment and to control spending on its own without congressional approval — though they've been subject to Congress' criticism, Kerns said the incoming administration may see value in keeping it around.
"Congress could also settle for limited authority,” Kerns said “but the truth is we really don't know."
Gilberg said that even though he feels the law is safe overall, because CMMI is embedded in the ACA, it could at least end up under the microscope. Just like the ACA, however, it can't be scrapped altogether without a viable alternative.
"CMMI and the billion dollars that come with it, is something that they'll definitely be looking at but they still have to create a pathway to alternative pay models," Gilberg said.
The Medicare Shared Savings program is also enshrined in the ACA, and is the main vehicle for alternative payment models. A shift away from MSSP as the main vehicle, possibly a dramatic one, is possible, along with some changes in bundled payment models as well.
"Pioneer and NextGen, mandatory bundled payments are part of CMMI. The ACA authorized CMMI to enact these as long as they were shown to save money and not damage quality. These are things that this Congress might be open to adjusting," Kerns said.
However, he does believe MACRA fits into a bipartisan reform landscape in general, since it repealed the sustainable growth rate and moved physicians towards performance-based payment, which has support on both sides of the aisle.
He listed three major points the industry should focus on in the coming months. First, he'll be looking at what kind of authority over payment reform congress wants to have over payment reform, something that could forecast whether CMMI survives. That is important for MACRA as the center develops many of the programs that count as APMs within MACRA.
Second, the new Congress' view of ACOs in general will be telling.
"Are they willing to continue to double down on them and use downside risk as a means of controlling spending or will they opt for reimbursement cuts moving forward?"
Third, it will be crucial to see how much emphasis Congress places on performance-based penalties and bonuses. This means looking at whether or note they are going to look to achieve their performance based payment by increasing the penalties and bonuses for quality performance, Kerns said.
The American Academy of Family Physicians said it doesn't believe MACRA as a whole is in any real danger of repeal.
"The election of Mr. Trump will have a limited impact on the MACRA law in the short-term. The law goes into effect January 1, 2017, before he is installed as president. Looking forward, this bi-partisan law was supported by 91 percent of Congress to bring about long needed value-based payment reform and repeal the flawed SGR. Based on the bipartisan support for the law, It is currently difficult to see how there would be any fundamental changes to the law under the Trump administration," said AAFP President John Meigs said in a statement.
Gilberg said that MACRA is a "living breathing thing" that will continue to evolve, even yearly, and where changes and adjustments should be expected, especially in 2018.
"There will always be refinements as we learn more in 2017 and we can expect this administration to be open to simplification,” Gilberg continued. “But I don't think the core is in jeopardy at all."