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What is CMS’s Pathway to Success and How it Empowers Physicians & Payers?

Abhinav Shashank
Fri 17 August 2018

What makes a person rate a restaurant excellent, average, or bad? Advertisements? References? Or personal experience? While multiple factors can influence one’s choices, their experience at the said place ultimately overpowers everything else. The healthcare sector is also rapidly catching up with consumer industries which justify costs based on experiences and services provided. The ongoing transformation in the sector looks like a prima facie case of making health care delivery patient-centric.

CMS is gearing up for making patients the center of care and going as far as terminating ACOs who perform poorly on the financial front for multiple years- a move to ensure that their spendings adhere to both, specified targets and growth rates.

But what actually lies beneath the buzz of “Pathways to Success?”

CMS recently came up with new guidelines to overhaul the Medicare Shared Savings Program called the “Pathways to Success.” The change is aimed at putting ‘accountability’ in ACOs with incentives that support value-based care like never before. As per the CMS, about 82% of the total ACOs taking part in the Shared Savings Program are not taking on risk for increase in costs even in 2018. But that looks set to change soon. And with that, many things are expected to change.

Going forward, the Star Rating evaluation will be more significant for provider and payer organizations. CMS is bracing for saving $2.2 billion over ten years for Medicare, something that would be in the line of advancing the goal of accountability, competition, engagement, integrity, and quality.

Given the more aggressive push for accountable care, it’s time that payers also take up the challenges of revolutionizing the care upfront. The condition is simple- add value to every care procedure or bear the burden of lower incentives. Currently, the rating system for payers has many implications, including:

  • Plans who score less than 3 stars for 3 consecutive years are flagged as low-performing. CMS can not only terminate them, but also send a notification to enrollees regarding the same.
  • Health plans which receive 4 or more stars are entitled to an incentive of about $500 per member per year. Further, plans who score a perfect 5 are eligible for a year-round enrollment period.
  • On the flip side, higher ratings implicitly translate to better credibility and reputation. Plans with high star ratings gain through high organic search and better traffic redirected on their websites which can further the number of attributed patients.

One simple solution: Know your patients better

A health plan’s rating is based on different measures such as how healthy the patients remain throughout, how well their chronic conditions are managed, how satisfied patients are with the overall services, among others. It is imperative for payers to involve themselves more aggressively in the care journeys of their attributed patients- how easily are they able to locate their providers, how contented they are from each episode of care, how much deductibles they are happy to pay for different services et al.

Patients who feel that their health plan is not helpful or less approachable tend not to follow the suggestions or reminders given by the plan. It’s about nurturing a trust-based relationship- with patients, and with providers. And this relationship should convert to patients getting the right information at the right time with the right technology. This essentially means that each patient is provided with the same content as clinicians by leveraging easily understandable and accessible technological solutions at the time when they are ready to learn.

But can that happen without the physicians’ support? No!

About 60% of the US population suffers from at least one chronic disease, and many of them fail to adhere to their treatment regimes. A large number of people are unable to effectively follow-up on their clinicians after an episode or surgery. Cases like these are many and disparate and account for higher admissions, readmissions, and even ED visits. These factors have a huge bearing on a plan’s performance when CMS reviews it at the end of each year.

More than anything, payers need physician champions and a mechanism for them to support patient-health initiatives at every step. Engaged physicians not only ensure improved quality outcomes, but also optimized practices to enhance star ratings. Payers need their physicians to be engaged if they wish to:

  • Improve patient health and educate them at every step
  • Identify early symptoms of diseases and enable preventive practices
  • Manage chronic diseases effectively
  • Increase the level of consumer-service and pay heed to individual needs
  • Reduce gaps in care

Why is provider-payer relationship the “pathways to success”?

If we continue on our present path, by 2026 we will be spending one in every five dollars on health care.

  • Seema Verma, CMS Administrator


Physician engagement is still widely seen as a concept specific to provider organizations. However, the healthcare kaleidoscope demands much more than our conventional wisdom. A while back, I came across a survey report by McKinsey & Company which concluded that only about 21% of Medicare Advantage Plan enrollees knew their plan’s Star rating. That was 3 years back, and much has changed since then. For instance, healthcare expenditure itself grew by 4.3 percent from 2015 to 2016 and is, unfortunately, ever-expanding.

There are no passive players in the sector. Not patients. Not payers. Not anymore. Providers arguably still are the center of patient-experience but with the ever-increasing regulations and protocols, payers, too, have become more accountable for patients’ health. Payer star rating matter more than ever before and is often a fine indicator of the quality of care and service provided by the providers in a payer’s network.

Unsurprisingly, much depends on how payers partner with their providers at every step of care delivery. It’s up to the provider and payer organizations how they empower their physicians with the solutions they need, the information they require, and the space they long for. Higher star ratings and higher profit margins will automatically follow.

The road ahead

Risk adjustment programs are designed to financially reward payers with higher medical loss ratios (MLRs) to ensure that they enroll high-risk beneficiaries. Federal agencies try hard to keep the interests of each player in health care intact. However, things can get complicated since no change is hundred percent smooth. Therefore, we need evolving partnerships. We need payers and providers to work together. We need leaders and physicians to come together for the greater cause. And we need to ensure that providing care and managing finances remain two mutually exclusive concepts- at all places, at all times. If that happens, we would reach the brink of experiencing five-star care!


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