Policy Update: Our Comments on the Proposed 2025 Physician Fee Schedule; Delays in MSSP Bonus Payments

By Casey Korba, Director of Policy

We have updates on our comments to CMS in response to the proposed 2025 Physician Fee Schedule, as well as the anticipated delay in distribution of Medicare Shared Savings Program (MSSP) bonus payments – due to CMS addressing the highly suspect billing from the potential catheter fraud situation – for the 2023 performance year.

Aledade’s comments to CMS on the Proposed 2025 Physician Fee Schedule 

We have finalized our comments to CMS on the proposed 2025 PFS and are deeply grateful to CMS for their continued efforts not only to refine and improve MSSP, but to welcome our feedback on how to improve it. Our comments focus on: 

• Quality-reporting: While we were excited to see some technical fixes to the scoring of the measures, we voiced our concerns around the additional quality measures being added, in the name of alignment, to electronic clinical quality measures (eCQMs) and Medicare Clinical Quality Measures (CQMs). We continue to emphasize that reported measures should focus on outcomes, not processes. Additionally, we continue to advocate for the best report card we can obtain for the least amount of burden and expense. We also reiterate that eCQM and total population reporting is both more difficult and less accurate. While we noted our appreciation of proposals to address some of the concerns through updating quality performance score thresholds, maintaining the eCQM reporting incentive, and adding the complex organizational adjustment, these proposals are not sufficient to offset the significant challenges ACOs continue to face. We continue to urge CMS to limit reporting of Medicare CQMs to the patient list provided by CMS at the start of the reporting period.
  
• Prepaid Shared Savings: Addressing the cash flow problem through the Flex model and initiatives like Prepaid Savings are incredibly helpful, but we are voicing our concerns over the many restrictions CMS proposed for the prepaid savings option, whereas shared savings do not have these restrictions.
  
• Health Equity Benchmark Adjustment (HEBA): Aledade supports the proposal of a HEBA for agreement periods starting January 1, 2025 and later. The HEBA would be the third positive adjustment available to ACOs, along with the positive regional adjustment for historically high-cost ACOs and the prior savings adjustment to account for previously earned shared savings. CMS would apply the highest of the three adjustments to the ACO’s benchmark. To be eligible for the HEBA, the ACO must have at least 20% of assigned beneficiaries with dual eligibility or low-income subsidy (LIS) status. The HEBA would have a maximum adjustment of 5% national per capita health expenditures, multiplied by the proportion of assigned beneficiaries with dual or LIS status. We note that relatively few ACOs are expected to benefit from the HEBA as proposed, and recommend that CMS expand the scope of the policy.
  
• RFI on Higher Risk Track in MSSP. We appreciate that CMS is continuing this important work to evolve MSSP and we have long advocated for a higher risk track option. We reiterated our previous comments on recommendations around a higher risk track that includes taking steps to avoid risk selection at the ACO and beneficiary level, avoidance of constraining the regional efficiency adjustment, and getting alignment on benchmarking with Medicare Advantage.

Finally, we look forward to heading to Capitol Hill this week to accompany Aledade member physicians and others in the ACO community to advocate for Congress to both address the physician fee cuts in the short term and implement long-term solutions to reform MACRA and physician payment in Medicare. 

Delay in distribution of MSSP bonus payments

• Payment Delay: Due to ongoing work by the Centers for Medicare & Medicaid Services (CMS) to address potential nation-wide catheter fraud and ensure the accuracy of the financial calculations, the results and payments for the 2023 performance year have been delayed.
• Payment Timeline: CMS has notified us of a delay of up to six weeks, which could push the release of shared savings bonus payments back as late as mid-November, for eligible practices.
• Reason for Delay: CMS is adjusting performance calculations to hold ACOs harmless for significant amounts of anomalous billing for catheter-related codes (A4352 and A4353). These claims are being excluded from the final calculations for 2023.
• Payment Implications: CMS has notified us that ACO participants may see increased shared savings bonus payments as a result of their billing corrections and variances at the ACO and practice levels. 

Of note, not all practices may be eligible to receive shared savings, as the final financial results depend on overall performance and CMS’s updated calculations. 

State Policy Corner

Over the past decade, several states have pursued efforts to increase the proportion of health care spending allocated towards primary care, with the overall objective being to promote a sustainable system of these practices that are well equipped to provide high-quality care to patients in their communities. In Arkansas, Aledade’s State Policy Team has driven momentum on this issue by convening a workgroup of local stakeholders to form an alliance and identify policy strategies. 

Through our partnership with this workgroup and the Arkansas Policy Committee participants, we expect to pursue strategic reform through the Arkansas state legislature in 2025. To support the success of this reform, the State Policy Team is designing a primary care investment advocacy campaign to highlight patient stories and illustrate the importance of primary care and its positive impact on communities.