FEATURE · ALTERNATIVE PAYMENT MODELS
Medicare And Medicaid Services: A Vision For The Next 10 Years,” the officials wrote that “After launching more than 50 alterna- tive payment models that reward health care providers for delivering high-quality and cost-efficient care, the Innovation Center has learned a great deal and is ready to build a stronger and more sustainable path forward. Beneficiaries, providers, and other stakeholders are encouraged by the work of existing models and are calling on the Innovation Center to lever- age those lessons. Don Berwick and Rick Gilfillan, a former leader of the Centers for Medicare and Medicaid Services (CMS) and an Innovation Center Director, respec- tively, recommended ways to connect the Innovation Center’s agenda to CMS’s and U.S. Department of Health and Human Services’s (HHS) goals for improving health and health care delivery; they also offered proposals to improve the Innovation Center’s model performance through, for example, changing the way Innovation Center models set payment and financial goals and measure quality. And MedPAC, a non-partisan legislative branch agency that provides the U.S. Congress with analysis and policy advice on the Medicare program, is considering draft recommendations related to the Innovation Center’s work that support a streamlined and more harmonized port- folio of models.” Importantly, the four officials wrote that “As now incoming leaders at CMS under a new administration, we have taken stock of lessons learned and begun to chart a path for the next ten years of value-based care. In undertaking this review, we con- cluded that we need a shared vision of the health system that we are collectively striving toward; we explicitly acknowl- edge health equity as a central goal for this vision. This focus aligns with President Biden’s day-one executive order charging each agency within the Administration to advance racial equity and justice for underserved communities.” So here’s how the models have shaken
out, as far as Brooks-LaSure and the other three CMS officials see it: “We learned something from every model launched to date,” they wrote in the August 12 blog. “So far, six models have generated statistically significant savings to taxpay- ers and Medicare: ACO Investment Model; Home Health Value-Based Purchasing Model; Medicare Care Choices Model; Maryland All-Payer Model; Pioneer ACO Model; and Repetitive, Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport Model. Four models have met the requirements to be expanded in duration and scope: Home Health Value-Based Purchasing Model; Pioneer ACO Model; Repetitive, Prior
Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport Model (expanded under MACRA, not section 1115A, authority); and Medicare Diabetes Prevention Program Expanded Model. The Innovation Center’s models span efforts to coordinate care for patients across care settings, such as through Accountable Care Organizations (ACOs); disease-specific approaches to improve care for people with kidney disease, can- cer, and diabetes; and approaches that try to address social determinants of health, such as Accountable Health Communities. Providers have risen to the challenge and participated throughout the Innovation Center’s evolution, from grant-based models to sophisticated total-cost-of-care models with shared financial risk. Notice what’s missing here? The
Medicare Shared Savings Program (MSSP), the largest program. I’ve seen little to no commentary in the industry about that omission, but it seems quite significant to me. What’s more, one could read the above paragraph a few different ways; but it’s hard to escape the conclusion that Brooks- LaSure, Fowler, et al have concluded that the MSSP is not generating enough savings to be retained long-term, while the Pioneer ACO Model seems to be in good favor with CMS/CMMI. This will be an area that provider leaders will need to monitor care- fully, for the next smoke signals coming out of the agency.
Meanwhile, the “six key takeaways”
are absolutely fascinating. To summarize briefly, equity and streamlining will be extremely important for LaSure, Fowler, et al. As they wrote in identifying the first of the six key takeaways in their blog, “The Innovation Center should make equity a centerpiece of every model. Models to date have been largely Medicare-oriented, and voluntary models have primarily drawn only those health care providers and organizations with resources and capital to apply and participate, resulting in lim- ited attention to Medicaid and safety net providers. From here on, the Innovation Center will embed equity in every aspect of its models by seeking to include more pro- viders serving low- and modest-income, racially diverse, and/or rural populations; the Innovation Center will aim to ensure everyone has access to providers at the leading edge of transformation.” Very significantly, the officials write, identifying their second key takeaway, that “Offering too many models is overly complex, particularly when models over- lap. The Innovation Center has launched over 50 models since its inception and is currently running 28 models concur- rently. Testing too many models at once can create opposing, even conflicting incentives and burden model participants
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with figuring out the model hierarchies and interactions. Ultimately, this not only makes decisions about joining or continuing to participate in models dif- ficult but also stymies systemic, scalable transformation.”
And, at least equally importantly, check out takeaways four and five: “Providers find it challenging to accept downside risk if they do not have tools to enable and empower changes in care delivery. The Innovation Center should ensure providers have options for manageable levels of risk as well as what they need to take on more risk, such as waivers, support in transforming care (particularly for vul- nerable populations), and data. This will require the Innovation Center to provide strong, consistent signals and expectations about where CMS is heading in value- based care.” And, “Challenges in setting financial benchmarks have undermined our models’ effectiveness. To address these technical issues, the Innovation Center is evaluating options to ensure models are not resulting in overpayment and explor- ing opportunities to improve or replace the current risk adjustment methodology.” I would urge our readers to read the
entire blog by these four officials, because there are very clear implications in it that could well reshape the alternative payment model world for some time to come. One could debate endlessly some of the specific implications of what they’ve written, but it’s clear that the Biden administration officials have strongly rejected some of the core assumptions underlying the previous administration’s thinking, particularly the thinking of Seema Verma. Indeed, take- aways numbers four and five could eas- ily be read as a total rejection of Verma’s thinking, as Verma spent a tremendous amount of energy trying to pressure pro- viders to take on downside risk, while not giving them sufficient reasons to take it on. The same could be said of their state- ment that “Challenges in setting financial benchmarks have undermined our models’ effectiveness. Translation: Brooks-LaSure and Fowler believe that Seema Verma completely failed at setting appropriate benchmarks to encourage providers to participate in APMs. So, yes: there’s a new sheriff in town, or
rather, a whole new sheriff’s posse. What’s clear is that Brooks-LaSure, Fowler, and their fellow officials at CMS and CMMI, have developed a strong, clear, conceptu- ally consistent rationale for policy devel- opment in the APM space, and that they plan to follow through on that rationale, as they rationalize the value-based pro- grams at CMS/CMMI. Expect them to move relatively quickly and decisively. Time for a new map to this new value- based policy world. HI
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