and also at the same time getting more value out of the development of alternative payment models. There was a sense of chaos, really, about Seema Verma and her leadership of CMS, in particular in relation to how CMMI was run. With its leadership revolving door, contradictions in apparent objectives, and lack of consistent philosophy or strategy, the apparent contradiction between “market-driven” philosophy and extreme heavy-handedness when it came to try- ing to force providers into two-sided risk, many provider leaders ended up speaking out on that core contradiction. The sense of relief on the part of provider leaders seemed almost palpable after the change in administrations. Last Thursday, the leaders of NAACOS, the National Association of ACOs, took the opportunity both to praise the performance of Next Generation ACO Model ACOs, based on performance data that CMS had released on that day, as well as to praise Brooks- LaSure and Fowler for the white paper and their statements in the press briefing the day before, Wednesday. “The impressive Next Gen Model results

are the latest illustration of the success of Medicare ACOs, benefiting patients, providers and taxpayers alike. Recent ACO results coupled with an enhanced commitment to accountable care from the Biden administration represent a notable paradigm shift toward achieving health- care transformation.” The press release went on to add that

“NAACOS was disappointed earlier this year when CMS declined our repeated requests to extend or make permanent the Next Gen program. With the program due to sunset at the end of this year, NAACOS continues to advocate that CMS develop a new full-risk option for ACOs under the Medicare Shared Savings Program (MSSP). This ‘Enhanced Plus’ option would advance ACO participation by creating a full risk and capitation option within MSSP, which to date has only been available in Innovation Center ACO models. This new model would also incorporate new benefit enhancements and incentives and create a better middle ground between MSSP and Direct Contracting,” NAACOS said. There’s no question that associations

like NAACOS are going to continue to press CMS and CMMI officials to give providers the best possible terms under which to participate in all the alterna- tive payment models. In that same press release, NAACOS’s Gaus was quoted as

stating that “Many Next Gen ACOs aren’t moving into Direct Contracting and have expressed a desire to have an ACO option that allows them to more gradually move toward capitation without feeling like they’re taking a step backward in their transition to value-based payment mod- els. CMS could use its waiver authority under the Innovation Center to create a new MSSP option we call ‘Enhanced Plus,’ much like it did with Track 1+, which was very popular and successful.” The NAACOS press release added fur- ther that “Today’s results compare Next Gen ACO spending to their pre-determined spending targets or benchmarks. The CMS Innovation Center has compared spending of Next Gen patients to that of non-Next Gen patients, but the comparison group includes beneficiaries assigned to MSSP and other Innovation Center models. That flawed comparison undervalues the suc- cess of the Next Gen model.” Indeed, the advocacy for better terms

seems if anything to be intensifying right now, given the challenging circumstances under which ACOs are operating. Just at week ago, a coalition of 12 national health- care associations and stakeholder organiza- tions urged Medicare to better account for the COVID-19 pandemic in accountable care organizations’ (ACOs’) financial tar- gets. Specifically, the groups, led by the National Association of ACOs, are ask- ing for an option to select pre-pandemic years on which to base benchmarks for their participation in the Medicare Shared Savings Program (MSSP), citing fairness in the way performance is measured in light of the global pandemic. In the October 14 letter, addressed

to Administrator Brooks-LaSure, the 12 coalition members wrote that “The Centers for Medicare & Medicaid Services (CMS) has worked hard since early last year to give our health system and provid- ers the tools needed to fully combat the ongoing pandemic. We greatly appreciate those efforts which have included modi- fications to value-based care programs, such as those for Medicare’s largest alternative payment model (APM), the Medicare Shared Savings Program (MSSP). However, further policy changes are needed to ensure the shift to value is not derailed by the highly unusual circumstances of the pandemic.” In fact, they wrote that “The country has seen and continues to experience tre- mendous variation in how the pandemic is affecting our healthcare system. Some

parts of the country were devastated in 2020 yet have now resumed more in-office preventive visits and elective procedures. For other areas, it was the opposite with 2020 providing little change in utilization from previous years, and doctors and hos- pitals now being hit hard by the pandemic this year. The pandemic has also affected which patients are attributed to ACOs. Since attribution is based largely on primary care services, and utilization patterns have been greatly affected by the pandemic, ACO attri- bution has been significantly impacted by various aspects of the pandemic, such as patients delaying care. The result for some ACOs has been major differences in ACOs’ attributed populations and performance year expenditures. These are out of an ACO’s control and not necessarily reflected in the benchmarks for which ACOs are held accountable,” the coalition members wrote to the Administrator. How to keep everything moving for-

ward will pose a very serious challenge to Administrator Brooks LaSure and Director Fowler. On the one hand, their overall strategic and policy thrust is clearly far more coherent than that of Seema Verma; on the other hand, they are managing CMS and CMMI at a time of heightened challenges, with the COVID-19 pandemic costing the federal government more than ever in patient care costs, while also sap- ping hospitals, medical groups, and health systems of some of their vital financial strengths. Indeed, reports from both the Chicago-based Kaufman Hall consulting firm and the Charlotte-based Premier Inc. health alliance last week documented pro- vider organizations’ considerable financial fragility in multiple areas right now. So, what’s the right answer to all of this? The answer is that there is no single answer. The pandemic has put pressure on the entire healthcare delivery and payment system as it has put pressure on U.S. society. There is no silver bullet here at all. And the thought process can become byzantine when one attempts to assess who/what should bear more burden right now, in order to get us all through this period in U.S. healthcare history. Should it be purchasers? Payers? Providers? Even consumers? There are simply no easy answers. But one walked away from last week’s CMS/CMMI press briefing with the sense that at least the people in charge have a better idea of what they’re doing—and a more strategic— and inclusive—vision of where they’re going—which is incredibly important. HI


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