For healthcare organizations and providers involved in a Medicare Shared Savings Program (MSSP), 2025 is truly a time of transition and a little uncertainty. When colleagues recently asked for my thoughts on MSSP this year, the old saying “May you live in interesting times” kept coming to mind.

In early February, we witnessed the confirmation hearings for Rober F. Kennedy Jr., and while at the time of writing (Feb. 3) the votes on his confirmation are not in yet, all indications suggest that value-based care and the Medicare Shared Savings Program both enjoy broad bipartisan support as well as support from RFK Jr. and the new administration.

With the combination of pending support and the pre-existing disruption caused by the phase-in of Version 28 (V28) of the Hierarchical Condition Categories (HCC) and steepening glide paths toward two-sided risk, it’s clear to lead and succeed with MSSP in 2025, organizations will need to focus on the fundamentals until the dust settles.

What are the Fundamentals of the Medicare Shared Savings Program?

As a voluntary program that encourages healthcare providers to coordinate care for Medicare beneficiaries, MSSPs aim to improve quality and reduce costs.

Generally speaking, there are four key fundamentals:

1. Attribution
2. Risk
3. Quality
4. Utilization/Resource Use.

These same four fundamentals also tend to apply in varying degrees to most commercial and governmental shared savings value-based care arrangements and represent the shared value proposition between patients, doctors, hospitals, and payors.

 

Understanding and Leveraging MSSP Fundamentals to Improve Quality and Lower Costs

With these fundamentals in mind, let’s quickly look at the key elements to understand about each one and how they relate to improving quality and cost savings.

 

1. Proper attribution helps improve care quality, health of patients, and financial results

Attribution or Assignment represents how a payor creates a population by assigning patients to a provider organization. MSSP uses a plurality of care attribution models and uses a series of HCPCS procedure codes to define primary care services and a series of provider specialty codes to determine the primary and specialty care providers assigned to the patient (and responsible for most of the patient’s care).

This is critical to understand because, with an MSSP, ACOs analyze the quality of care your Medicare patients receive and share payments with your providers accordingly. So when Medicare patients are correctly attributed to the ACO organization and the ACO provides excellent, cost-effective care, this translates to the ACO receiving additional funds and the relevant provider practice(s) will receive a pre-defined portion of the savings the ACO generated from Medicare.

Success tips:

1. Ensure patient claims are properly analyzed to identify high-quality, high-performing providers so that patients can be properly assigned for better health outcomes and care management.
2. Leverage analytics within a care management platform to get a more comprehensive and real-time view of how different providers are impacting patient health, and to get ahead of any potential (high-cost) risks that may arise.

 

2. Calculate risk scores to estimate shared savings and identify high-needs patients

Risk is a critical element of MSSP. Risk scores influence both the proactive execution of evidence-based interventions for patients and the financial benchmark an ACO is measured against. Higher score, higher benchmark, more money to spend on high-needs patients while still hitting savings compared to benchmarks.

Properly addressing risk entails ensuring that as many attributed patients as possible have received accurate and comprehensive ICD10 Dx codes representing all of the conditions that are being monitored, evaluated, assessed, and/or treated.

Since risk scores determine how much shared savings can potentially be earned, it’s critical to understand the following:

• Performance Year 2025 is two-thirds V28 and one-third V24, but 2025 is based on ICD10 Dx codes recorded during the calendar year 2024
• The ICD10 Dx codes recorded in 2025 will set the risk scores for the patients in 2026
• We are now coding in a 100% Version 28 environment, where over 2,000 ICD10 Dx codes have been removed

It is also critical to understand that CMS has limiters such as certain HCPCS codes that must accompany the diagnosis. Understanding the rules of this complex part of the shared savings program is critical to success.

 

3. Be Conscious of Changing Quality Measures

Quality Measures continue to morph and change.  As you are reading this, you are likely more focused on getting 2024 completed and submitted.  The minute 2024 is completed make note that 2025 MSSPs must report on a new set of quality measures called the APP Plus Quality Measure Set which under current rules will consist of the following measures:

• Diabetes: Hemoglobin A1c (HbA1c) Poor Control (Quality ID #001)
• Preventive Care and Screening: Screening for Depression and Follow-up Plan (Quality ID #134)
• Controlling High Blood Pressure (Quality ID #236)
• Breast Cancer Screening (Quality ID #112)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey (Quality ID #321)
• Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups (Quality ID #479)
• Clinician and Clinician Group Riskstandardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Quality ID #484)

 

4.  Look to Preventive and Proactive Care Management to Reduce Wasteful Utilization / Resource Use

Utilization/resource use is about “avoiding avoidable exacerbations” through better proactive and preventive care.

Providers naturally focus on diagnosing and treating patients and don’t necessarily tend to focus on reducing admissions, ER visits, or other services. This is where a unified care and utilization management platform and collaborative relationship between the ACO and providers come in.

A single-source-of-truth platform for care and utilization management can provide a unified and comprehensive view of all served individuals and facilitate faster awareness of health risks and conditions that can then be addressed proactively for lower costs. Built around the patient, this kind of solution can create a more patient-centered approach and improve inter-provider communication and visibility to both patient health needs and healthcare usage. In doing so, the likelihood of reducing avoidable exacerbations increases yielding reduced utilization of key services that are no longer needed.

 

Improve the Foundation for a More Stable Population

Focusing on the fundamentals throughout 2025 will lend greater stability to your population management approach and help drive higher financial rewards. By improving your attribution, your population will become more stabilized year over year.  With a more stable population, the ICD10 Dx Codes you record for patients this year will stay with you. The codes CMS has identified for attribution also cross over to improved care management and preventive care which in turn helps to reduce avoidable exacerbations.  The more you are engaged with the patients, the better chance you have that you will improve your quality scores.

A final thought: Each of the four areas cross-feed one another, so in a world of limited resources, ensuring you have the right technologies in place to stay on top of all of these critical tasks is going to be key.

Kevin J. O’Brien is the EVP – Head of Analytics & Data Science at Elligint Health and has served as a leader and key executive in accountable care initiatives for over 25 years. A nationally recognized expert in care coordination, chronic disease management, and healthcare analytics, O’Brien previously was the EVP – Head of Analytics & Data Science at HealthEC and served Partners In Care (a NJ MSO) from 1995 through 2013 in various capacities including eight years as CEO, a member of the Leadership Committee of the New Jersey Healthcare Quality Institute, a member of the CIGNA National Health Care Advisory Council, and a co-chair of New Jersey’s Regional Action Coalition Nursing Initiatives Taskforce Data Workgroup.  Today, O’Brien continues to seve as a Senior Fellow for the NJ Healthcare Quality Institute and a member of the NJ Department of Health’s Quality Improvement Advisory Committee.