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incentivize organizations to move into risk-based APMs. And I think we’re all seeing that. I work with about 75 health systems and clinically integrated networks (CINs) in our population health management collaborative, and many of them are already taking on two-sided risk in the MSSP [Medicare Shared Savings Program] and in MA. And we’re seeing a downstream impact of that in the commercial and employer space as well. That movement could catalyze other organizations to move into the MSSP, which has a determined path into two-sided risk. So I think we’ll see that hap- pening more and more among all ACOs, including health systems.” What about the Medicare Shared Savings Program and its bench- marks? Much controversy emerged over the course of the Trump administration, as CMS Administrator Seema Verma appeared to battle with some provider associations over how the benchmarks in the MSSP program are organized and applied. “There’s a con- fusion around whether or not we should use the benchmark to determine whether the program is being successful,” Edwards says. “It’s important to call out that benchmarks aren’t counterfac- tuals; they’re not accurate ways to determine how successful the program is. These organizations are generating savings for CMS. There’s really important context for policy for those models as they go forward. The next step becomes, why are they pushing additional amounts of risk? At CMS, they believe that it prods greater performance. But it’s really challenging to say, in the model, you get two years under Pathways to Success before you have to take on downside risk;
Seth Edwards
that’s a very short time. The longer organizations are in the program, the more successful they are. So there needs to be a conversation around that, as well as to make sure there’s a level playing fi eld around the classifi cations of different ACOs. So I would imagine there would be a look at that, as well as the underlying incentives for taking on additional amounts of risk.” Indeed, Edwards says, “I think there could be an acceleration, not so much directly tied to risk, but more weighting of the base models in terms of the bonuses and discounts that might be applied. I do think that the public health emergency is creating a dynamic where economically or politically, it could benefi t a discussion of the defi cit and debt, and a large proportion of that expenditure is driven by healthcare.”
Beyond those issues, others hover on the horizon, including
in the area of telehealth, say Darryl Drevna and Jamie Miller of the Alexandria, Va.-based AMGA (American Medical Group Association). Drevna, the association’s senior director of regula- tory affairs, says that “MedPAC [the Medicare Payment Advisory Commission] is looking at how to modernize telehealth under the law.” And, among the issues the commission is looking at is the set of regulatory restrictions in place around geographic restrictions for providers of telehealth-based care delivery and others. Those restrictions were waived last March, but will have to be looked at once the public health emergency ends (currently set for the end of this calendar year). “That’s defi nitely on their agenda,” he says. And, says Miller, the association’s senior director of govern-
ment relations, “The discussion between committees in the House and the Senate, is around utilization.” And in the context of the potential change in the permanent regulations around telehealth, he says, there is a strong motivation there for legislators to help the healthcare system to save costs by making permanent all or most of the regulatory relaxations around telehealth ushered in by CMS last March. HI
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something about it requires money and resources. The last year has provided that catalyst for boards to realize that they have to put some money into this — like serious money.”
Equity efforts in Medicaid managed care Shilpa Patel, Ph.D., the associate director for health equity at the Center for Health Care Strategies (CHCS), leads multiple projects that support states and healthcare systems to advance health equity for people served by Medicaid. She notes that Medicaid agencies are increasingly focusing more on equity and operationalizing their commitment and priority to equity in different ways, including taking value-based purchasing approaches. “We’re seeing that state Medicaid agencies and their partners, Medicaid managed
“Our executive pay is tied to reducing maternal morbidity and mortality among Black and Brown populations and increasing colorectal screening among our Black population.” —Kevin Mahoney
care organizations (MCOs), are working with provider groups to reduce disparities for the Medicaid members,” she says. CHCS’ Advancing Health Equity initiative is working with Medicaid agencies, MCOs and provider groups to develop and implement care delivery transformations and payment approaches. Patel says these efforts are driven by data at the plan and state level, so organizations must use the data they have to identify disparities as well as mechanisms to bolster their capacity to either collect and report on the data. “We’re also seeing some stakeholders using contracts between the health plans and providers to either require or fi nancially incentivize measurement and tracking disparities, and as part of that, helping them afford the infrastructure required to monitor and track reductions,” Patel adds. “The COVID pandemic has really galvanized the need to stratify data in order to tailor your efforts. So hopefully we can use some of that momentum more broadly as part of these Medicaid innovations, and also use either existing or planned value-based contractual requirements as a starting point.” States, payers and provider organizations are assessing how
progress toward an equity goal will be measured through perfor- mance measures, she says. For instance, Oregon has used a metric around emergency department utilization intentionally focused on reducing disparities for people experiencing mental illness. Michigan has included in its Medicaid managed care contract initia- tives to improve low-birthweight babies and have incentivized this through their contracts. “They also have an Index of Disparity that they’re using for their plans to identify and track their reduction in disparities,” she notes. If state governments are making some progress, Chin says that
frankly, the federal government has done relatively little so far. “They have talked about it in some of the innovation grants such as Accountable Health Communities,” he says, “but with all the interest in alternative payment models, they are at very early stages of thinking about value-based payment with an equity lens.” Chin says it seems that sometimes people use a form of “magical thinking” to believe that value-based payment and alternative payment programs are going to fi x everything. “Well, not if they are not intentionally designed,” he says. “There are a lot of ways to get around addressing equity issues — hence the virtue of designing the incentives to do the right thing. The vast majority of providers in healthcare would love to do the right thing, but they’re working under rules of the game which don’t enable them to do the right thing in the long term.” HI
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