The Medicare Shared Savings Program (MSSP) is undergoing a major overhaul under the Pathways to Success regulation, finalized December 31, 2018. This regulation replaces the existing program participation tracks with an emphasis on increasing downside risk, as well as updates a variety of other program rules. This rule went into effect on January 1, 2019, with most aspects to be implemented fully starting July 1, 2019.
The Patient Protection and Affordable Care Act (P.L. 111-148 as amended) required significant reductions to Medicaid payments to hospitals that serve a disproportionate share (DSH) of low-income and vulnerable patients starting in 2014. However, the start of Medicaid DSH payment cuts was delayed several times by policymakers. In 2013, Congress postponed the beginning of payment reductions to 2018, and budget bills in later years continued to postpone the cuts.
Last August the Centers for Medicare and Medicaid Services (CMS) provided a one-time retroactive opportunity to withdraw in total from the BPCI Advanced program or withdraw selected clinical episodes by March 1, 2019. This grace period allowed participants to “test the waters” between October 2018 and February 2019 before making a final decision. Participants that retroactively withdraw in total or for select clinical episodes will not be held accountable for those episodes. Meaning that any losses incurred relative to the established target prices will not be charged to the bundler.