Thriving in the MSSP: 8 Lessons from 8 Years (Part 2)

Editor’s Note: Click here to read “Thriving in the MSSP: 8 Lessons from 8 Years (Part 1)”

From cultivating physician leadership to improving patient access, success in the Medicare Shared Savings Program (MSSP) requires a multifaceted strategy. This strategy must encompass everything from governance to technology, patient access to physician engagement, and more.

The scale and complexity of such a strategy may deter physicians from entering the MSSP or other value-based arrangements. Shifting to value-based care involves many changes that impact your entire practice and a certain degree of uncertainty is unavoidable when making the volume-to-value transition. However, by empowering everyone to contribute their unique expertise, you can approach this transition from a place of inspiration and curiosity rather than fear.

To demystify the various aspects of the MSSP, we’ve gathered tips and insights from a diverse group of experts. Before we begin, here’s a quick recap of the topics covered in part one of this two-part series:

• Lesson #1: Start With the Right Physicians
• Lesson #2: Access, Access, Access
• Lesson #3: Don’t Skip the Annual Wellness Visit (AWV)
• Lesson #4: Integrate Data-Driven Actions at the Point of Care

Lesson #5: Put Data in Front of Physicians

Fred Taweel, MD, Chief Medical Officer, Privia Medical Group — Mid-Atlantic

As doctors, one of our greatest strengths is combining objective and subjective information to draw conclusions. We understand not only the hard science behind treatment plans, but also how to translate and communicate the facts to patients while nurturing that valuable relationship.

Similarly, succeeding in value-based care requires us to analyze the data then modify our behaviors accordingly. Data is useful only when shared meaningfully. To advance value-based care, it’s essential that you establish a culture of transparency and accountability through data sharing.

One area to apply these data-sharing practices is your governance structure. I’m a firm believer in physician-organized delivery (POD) groups, sub-groups of our accountable care organizations (ACOs) determined by doctors’ locations. During our routine POD meetings, we openly broadcast participants’ metrics. This leads to positive conversations, with leaders sharing action plans and best practices that build buy-in and effect change. Our discussions are always constructive. We don’t criticize but rather encourage each other to reach peak performance. This helps build a team of “great, motivated docs,” to echo my comments to the American Medical Association. The atmosphere is collaborative yet competitive, creating the conditions under which we as healers so often thrive.

When it comes to data sharing, physicians are ultimately the stewards. Value-based care starts with actionable data and ends with better patient care. As physicians, we are the conduit between the two. Transparent, collegial governance enables us to unite, share insights, and transform healthcare — together.

Lesson #6: Use a Common Health Record

Tiffany Johnson, Director of Quality, Privia Health

A 2021 survey from the National Association of ACOs (NAACOS) found that “nearly half of ACOs’ participating practices use 11 or more EHRs.” Researchers cited the lack of standardization and interoperability as primary obstacles in moving to electronic clinical quality measures (eCQMs). Such a move requires ACOs in the MSSP to gather data from various (and often incompatible) EHRs. Reporting quality data on all patients using these disparate systems may lead to serious issues, possibly even worsening health disparities.

Until we reach seamless interoperability, the ideal solution is for all providers in an ACO to use a single, shared health record. Doing so can simplify data aggregation and submission to help ensure ACOs and participating physicians are fairly reimbursed. Additionally, this approach streamlines data sharing and improves workflows to satisfy metrics. Such constructive conversations are difficult — if not impossible — when using disparate and disjointed health records.

We owe it to providers to help reduce EHR-related administrative complexity. Research shows that two-thirds of physicians list EHRs as a driver of burnout. With so many providers struggling today, it’s essential that we find solutions to support and alleviate burnout. Our efforts help not only advance the Quadruple Aim’s goal of promoting provider well-being but also advance value-based care by enhancing performance in models like the MSSP. Implementing a shared health record can accomplish these goals and boost the “organization” in “accountable care organization.”

Lesson #7: Deliver Savings to Physicians

Sam Starbuck, Vice President and General Manager, Privia Quality Network

In order to retain and increase the number of participants in the MSSP, it’s vital that physicians receive fair rewards for delivering valuable care. “Value,” to put it simply, means high-quality, cost-efficient care that improves health outcomes and, as a result, lowers total spending.

The necessary administrative layer through which savings pass before they get to the physician is too often poorly defined and misunderstood. In many cases, this administrative layer devours savings that should rightfully go to the physicians who generate the savings in the first place. It’s imperative that ACO administrators clearly explain how payment processes work. With this clarity comes assurance, which in turn enables physicians to focus on what they love and what they do best: providing high-quality, patient-centered care.

The following three principles are critical when articulating the ACOs’ administrative processes to motivate, engage, and build buy-in among participating physicians:

• • Physician-Led. ACO members should have a seat at the table for discussions regarding the distribution of earned savings. This empowers physicians to offer their unique expertise and better understand how their work generates and disseminates shared savings. Physician leadership is incredibly important to ACOs’ success. Research shows that physician-led ACOs generate nearly seven-times more savings than hospital-led ACOs.
  • Transparent. First, physicians should know how the ACO will distribute savings before the performance year starts. This includes reviewing and communicating key metrics and participation requirements. Second, physicians should have insight into investments the ACO makes to support operations. Doing so enables physicians to forecast future earned savings by accounting for and deducting these investments.
  • Purpose-Built. From performance metrics to the different reward opportunities for high and low performers, ACOs should strive to incentivize, measure, and reward the actions and behaviors that lead to improved outcomes and lower costs for the patients.

Lesson #8: Keep Skin in the Game

Mark Foulke, Executive Vice President of Transformational Value-Based Care, Privia Health

To meaningfully advance value-based care, the industry needs to advance risk-based care. A few years back, MSSP redesigned their model to accelerate the shift from allowing “upside-only risk” to forcing groups to “downside risk.” It’s helpful to think of upside as the “carrot” and downside as both the “carrot and the stick.” In upside arrangements, ACOs receive savings that result from more efficient, high-quality care delivery. In downside arrangements, ACOs can receive even greater savings for this optimized care delivery but are also financially responsible for losses if they fail to meet their contracts’ clinical and financial thresholds.

As such, downside risk can be intimidating as it holds ACOs more accountable — accountable for wins as well as losses. Having said that, I believe there are proven strategies to mitigate risk. Success in value-based arrangements like the MSSP begins, but does not end, with a signature on a fair and equitable contract. Contracts dictate the metrics and thresholds that ultimately determine savings and performance. However, there’s a crucial element between the signature and the potential reimbursement, and that is behavior.

Behavioral change is not a one-time quick fix but rather the result of proper processes. The contract sets the goals while processes drive the day-to-day behavioral and workflow changes that value-based care necessitates. As James Clear, a thought leader on the topic of habits, once wrote: “You do not rise to the level of your goals. You fall to the level of your systems.” Therefore, ACOs should implement processes for both patients and providers that align with contractual requirements and motivate consistent behaviors.

To benefit patients, processes should center on engaging and empowering patients to understand, manage, and own their healthcare. For providers and staff, processes should similarly emphasize patient engagement. Provider processes must also identify key factors for success (as stipulated by the contract) and their impact on the most precious resource — time. This can be difficult as care teams are already extremely busy. However, the initial investment of time can lead to a tremendous ROI in downside-risk arrangements.

Under upside-only arrangements, it’s easy to forgo these critical steps, which in turn fails to promote the behaviors that will advance value-based care. By entering into downside risk — getting skin in the game, so to speak — these steps become essential. Although upside arrangements, such as the MSSP’s Basic track, can help attract and welcome participants who are new to value-based care, it’s the downside arrangements, such as MSSP’s Enhanced track, that truly advance value-based care by raising the bar and stakes for performance.

Conclusion

“Over the last decade, Medicare has promoted participation in value-based care to reward better care, smarter spending, and improved outcomes,” CMS Deputy Administrator Meena Seshamani, MD, Ph.D., said in a statement. “As we continue working toward our goal of increasing the number of people in a care relationship with accountability for quality and total cost of care, we … know we have more work to do.”

While the details of the MSSP, ACOs, and value-based care will continue to change and evolve, we believe the central tenets will remain intact. At their core, these models ultimately revolve around creating a more sustainable and fair healthcare system and experience. To assist in this transformation, we must enable and empower physicians, helping doctors help patients.

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