Advocacy Group Urges CMS to Create Payment Model Targeting Long-Term Care

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) has released a white paper urging CMS to develop a value-based care model focused on the needs of the long-term care (LTC) population. 
 
AHCA/NCAL, which represents more than 15,000 skilled nursing centers, assisted living communities, sub-acute centers, and homes for individuals with intellectual and developmental disabilities, says that current ACO models do not fully support LTC residents because they were designed primarily for seniors living in the broader community and are centered around clinician-driven care. 

This structural misalignment leaves many LTC providers without a clear pathway for meaningful participation in ACOs and value-based care. As a result, fewer than 10 percent of skilled nursing facilities currently participate in ACOs. Tailoring a model that explicitly addresses the unique needs of the LTC population would unlock substantial opportunities for increased participation, improved outcomes, and Medicare savings, the white paper says.

Last November, Healthcare Innovation covered a talk by Kristen Krzyzewski, chief strategy and program development officer for Long-Term Care ACO, in which she highlighted some of the challenges and successes in navigating the Medicare Shared Savings Program with a long-term care focus.

Speaking at the NAACOS fall meeting, Krzyzewski explained how its patient demographics impact the ACO’s areas of focus. “In care delivery we're really focused on preventing unplanned hospitalizations. We don't want our patients to have to go to the hospital unless that's the absolute right place for them to be. But in the nursing home setting, if the primary care isn't available and the facility staff members have a question or concern, they're going to send the patients out,” she said. “Weekends and after hours, the patient's going to go to 911, to the hospital, and that will typically result in a hospitalization and create a lot of risk. We see that as an adverse quality outcome, so our participating providers are focused on preventing those hospitalizations, and now that they're accountable for the total cost of care, they're really engaged in trying to minimize that risk. We work with predictive analytics models to identify who's at greatest risk for going to the hospital for an admission, and we arm our providers with that information so they know within a high-risk population, who's the highest, highest risk.”

Krzyzewski also noted that although LTC ACO is committed to quality, by the nature of its population and the quality measures used in the program design, they are at a disadvantage.
 
AHCA/NCAL has specific recommendations for CMS in the development of an LTC ACO-specific model, including:
    •    A specific attribution methodology to improve participation and accountability.
    •    Financial incentives and flexible risk-sharing options.
    •    Streamlining quality measurement.
    •    Incentivizing interoperable technology adoption.
    •    Promoting wellness and chronic disease management, especially in the assisted living setting.
    •    Prioritizing underserved LTC populations and facilities with limited resources or infrastructure.

“Our recommendations aim to solve the vulnerabilities in existing ACO models and leverage the expertise of our providers in support of CMS’ goal to align financial incentives with improved health outcomes for all Medicare beneficiaries,” said Nisha Hammel, AHCA/NCAL vice president of population health management, in a statement. “This is an opportunity to address the realities of long-term care settings and advance coordinated, quality care. We look forward to working with CMS on advancing these value-based solutions.”
 
The white paper notes that a recent analysis by ATI Advisory found that Medicare fee-for-service (FFS) spending for LTC residents aligned to an ACO is significantly lower than spending for residents who are not aligned. In 2023, Medicare FFS spending on the average nursing facility and assisted living resident aligned to an ACO was 11 percent and 19 percent less, respectively, than unaligned residents. ATI Advisory also estimates that adopting the recommended model could generate more than $2 billion in savings to Medicare each year.
 
“The benefits to residents and the Medicare program are clear,” said John Kane, AHCA/NCAL senior vice president of reimbursement policy, in a statement. “CMS should recognize the unique value proposition long-term care offers this medically complex population and address current barriers to ACO participation. AHCA/NCAL remains focused on improving these value-based care models and preparing providers for this evolving reimbursement landscape.”