Milliman is the latest to point out a crisis in Medicare Shared Savings Program #MSSP. With prediction comes risk, but what happens when the prediction is devastatingly off costing #ACO hundreds of millions? We have to fix it is what happens. 1/

My favorite chart tracking the outcomes of the reweighting of E&M that occurred in 2021 updated with 2026.

The conversion factor is up 3.83%. The extra beyond the 2.5% comes mainly from the 90% reduction is expected skin substitute spending and changes in the efficiency adjustment calculation that increase it over last year. That is a wrap for immediate rxs. 18/.

@CMSinnovates Interesting tidbit for care teams. CMS proposes to make permanent virtual supervision for incident-to services. 17/.

@CMSinnovates Essentially the model is going to test whether a robust MIPS can change behavior while guaranteeing CMS 15% of 9-12% savings by just cutting aggregate payments by that amount. 16/.

@CMSinnovates Just got to keep reading. 9 percent in the first year growing to 12 percent by the last year. 15/.

@CMSinnovates Though 9% was used in the example so maybe it going to be roughly the same level. 14/.

@CMSinnovates No declaration of how much of the Medicare payments will be at risk. I would assume that it will be at least +/-10% because MIPS already has +/-9% on paper so there wouldn't be a need to design a model outside of MIPS if we weren't going for a higher level of payment effect. 13/.

@CMSinnovates There is a complex patient adjustment to the measures which is a complex thing to do but needed given that this model faces a lot of small number problems. 12/.

@CMSinnovates Very unfortunately the model keeps MIPS two year timeline where performance in 2027 will effect payments in 2029. That delay has proven to all but eliminate the day to day behavioral effects of MIPS. 11/.

@CMSinnovates Short version is the model is what MIPS was supposed to be in the law but never was fully implemented as CMS made it so easy to avoid being penalized in MIPS there was never any funding to reward success in a meaningful way. 10/.

Up next our neighbors in @CMSinnovates have a new ambulatory model. 9/.

Measured trends like most of those used to great success in #MSSP are crudely protective of ACOs from events like the skin subs, but not completely. Furthermore, the taxpayer is not protected by trends they fund trends so good to see major action here. 8/.

Turning from #MSSP provisions to those effecting #MSSP. Skin substitutes get their own fact sheet. CMS is proposing to pay for skin substitutes as incident to supplies from biologicals knocking 90% off the spend. 7/

As you would expect for a new administration not a ton there on the first rule. It is usually the second rule where the action is particularly around MSSP. Tackling CHOW is a big wonky bit for the first go. We certainly expect a lot more action on admin benchmarking next year. 6/.

Along those same lines of new organizations trying to allow new orgs to join MSSP sooner by only requiring 5,000 beneficiaries in the most recent benchmark year. Increases volatility so capping savings and losses at lower rates for those ACOs. 5/.

One of the biggest benchmarking challenges is dealing with CHOW so will have to dive into this one closely. One of those areas that does need to be address but the details are everything. 4/.

New requirements for when an ACO participant undergoes a Change of ownership during the performance year. 3/.

As per usual will start with #MSSP, starts off with walking back the Basic and Enhanced from the changes made a few years ago to near the original Pathways to Success rules of 5 years in Basic and then Level E or Enhanced. 2/.

2026 Physician Fee Schedule is out. Looks like they did hold it back to get the 2.5% in.

Update: CMS has adjusted the weight of the 2024 ACPT to 1/6, which suggests that we have not fully persuaded everyone at CMS to eliminate ACPT in favor of building a better-designed, regionally driven administrative benchmark.