Year in Review: Value-Based Care and Alternative Payment Models

Dec. 28, 2022
Dora Hughes, M.D., M.P.H., chief medical officer at the CMS Innovation Center, said the center’s 10-year anniversary was a good time to look both back and forward at how its models impact health equity

In the world of value-based care and alternative payment models, 2022 has seen a heightened focus on health equity. In March, Dora Hughes, M.D., M.P.H., chief medical officer at the CMS Innovation Center, said the Innovation Center’s 10-year anniversary was a good time to look both back and forward at how its models impact health equity and how the organization can do a better job of measuring the models’ impact.

Speaking on a March 23 panel at the University of Michigan’s Center for Value-Based Insurance Design, Hughes said that at the 10-year anniversary of the CMS Innovation Center, it made sense to take a step back and think about what it has accomplished and what they had learned from the past 10 years, and where it wants to go to achieve a health system with equitable outcomes.

In advancing health equity, Hughes described four main areas of focus. “The first is as we are creating new models or modifying models, how are we embedding health equity? What are the care delivery interventions? How are we recruiting? What are some of the payment considerations?”

The second area of focus is the recruitment of safety net providers, including Federally Qualified Health Centers, rural health clinics, and behavioral health clinics. “We're focused on that, in part, because we need to increase the number of beneficiaries from underserved populations who are participating in our models,” she said.

The third area is an enhanced focus on evaluation. “At the end of the 10 years, when we took a look back, we realized that because we weren't specifically asking ourselves what is the impact of our models on health equity, we don't know actually what impact they've had on access and quality of care for underserved populations,” she explained. “So the CMS Innovation Center is trying to be very deliberate from the very earliest stages of conceptualizing models in terms of understanding the questions they have to ask to get to a robust evaluation.”

The final area is focusing on strengthening the collection of demographic data as well as data on social determinants of health. CMS recognizes that greater data availability is key to monitoring and evaluating its models and to inform design.

ACO REACH participants chosen

A prime example of the equity focus is the new ACO REACH model, which is an evolution of the Direct Contracting model and will test how providers can be incentivized to collaborate across multiple treatment plans, spend more time with patients with complex, chronic conditions and ultimately, improve patient health outcomes. To better support care delivery and coordination for patients in underserved communities, each model participant must design and implement a comprehensive health equity plan that identifies its underserved communities and establishes initiatives to measurably reduce health disparities within their beneficiary populations.

In August, CMMI named the 110 participants provisionally accepted to participate in the ACO REACH model starting next year. CMMI accepted fewer than 50 percent of applicants, and 18 organizations withdrew their applications after receiving provisional acceptance. 

In one example of an ACO REACH partnership, the Medical University of South Carolina (MUSC Health) and value-based healthcare company UpStream Healthcare say will create opportunities for providers to improve key metrics and improve clinical outcomes for patients, while strengthening the coordination of primary and specialty care within the network. More than 300 primary care physicians caring for more than 30,000 seniors are expected to participate.

A goal of the program is to advance health equity for the underserved with a focus on preventive care and managing chronic conditions. The UpStream platform recognizes that primary care physicians have the ability to serve as quarterbacks for their healthcare system. Pharmacist-led teams are embedded into primary care providers' practices along with nurse coordinators who perform home visits to coordinate care and ensure patients' needs are met. UpStream provides the technology to support the workflows of this care coordination model.

Paying for equity

Commercial payers are also turning their attention to health equity. Continuing to be a leader in the “pay-for-equity” movement, Blue Cross Blue Shield of Massachusetts announced in December that four of the state’s largest healthcare systems have signed agreements that link financial incentives to improvements in health equity.

The four health systems are Steward Healthcare Network, Beth Israel Lahey Health, Mass General Brigham and Boston Accountable Care Organization Inc., which is part of Boston Medical Center. Together, these systems provide care to more than 550,000 Blue Cross members. 

The nonprofit Blue Cross, which has 2.9 million members, said the new contracts will initially focus on measuring and rewarding equity in care in several clinical areas where inequities have been identified, including colorectal cancer screenings, blood pressure control and care for diabetes. Additional categories will be added as the payment model evolves. 

Enhancing Oncology Model

The Oncology Care Model (OCM), an alternative payment model CMS launched in 2016, came to an end on June 30, 2022. As a follow-up, CMS has announced the Enhancing Oncology Model (EOM) to build on some lessons learned in the OCM and to add an equity focus.

EOM is a voluntary model that will run for five years, from July 2023 through June 2028. Model participants will include oncology practices that treat people with Medicare undergoing chemotherapy for breast cancer, chronic leukemia, lung cancer, lymphoma, multiple myeloma, prostate cancer, and small intestine/colorectal cancer.

Participating providers will also provide enhanced services such as patient navigation, care planning, collection of electronic patient-reported outcomes (ePROs), and screening for social needs that may affect treatment, such as transportation issues and nutritional needs. EOM will also encourage other payers to align with its core concepts to promote a consistent approach across payers and EOM participants’ patient population.  

An APM strategy for specialists

During a fireside chat held at November’s Health Care Learning and Action Network summit meeting, the Center for Medicare & Medicaid Innovation’s Sarah Fogler, Ph.D., M.A., reflected on CMMI’s decade of experience with creating alternative payment models for specialty care, and also spoke about upcoming opportunities in this space.

Fogler noted that the CMS Innovation Center has established a comprehensive strategy to incorporate specialists into value-based payment programs aligned with the CMS Innovation Center Strategy Refresh. Fogler said that in addition to episode-based payment models, CMMI has made gains through specialty models that focus on conditions — specifically for oncology and kidney disease, including the Oncology Care Model and the new Enhancing Oncology Care Model and Kidney Care Choices and the comprehensive ESRD model. “There are remaining opportunities around fragmentation between primary care providers and specialists, increasing access to high-quality specialty services, and getting more specialists involved in value-based payment generally. So that's where we're focusing key areas in our specialty strategy moving forward.”

Increase in two-sided risk models

The percentage of healthcare payments tied to two-sided risk APMs continued to increase from 2020 to 2021, according to data released at the 2022 Health Care Learning and Action Network’s (LAN) annual summit in November.

The LAN, launched in March 2015 by the U.S. Department of Health & Human Services (HHS), brings together public, private, and nonprofit sectors to link healthcare payments to quality and value through the increased adoption of APMs.

The LAN has reported statistics on APMs since 2016 and released the 2022 APM Measurement Effort, a compilation of 2021 APM data, at this year’s meeting. In an ongoing effort to address health equity, the LAN also released Guidance on Social Risk Adjustment, which was described as a starting point for acting on three core components of social risk adjustment: data collection and tools, payment incentives and mechanisms, and care transformation.

The report shows an uptick in healthcare dollars tied to two-sided risk APMs across the Commercial, Medicare Advantage, and Medicaid lines of business compared to 2020 data, with Medicare Advantage showing the biggest increase of 5.8 percentage points. Traditional Medicare held steady from the previous year.  

“I think the headline is that we've made a lot of forward progress in the past year creating more opportunities for providers to participate in alternative payment models,” said Ellen Lukens, M.P.H., the deputy director of CMMI, during a panel discussion on the measurement results. “We increasingly understand that we need to meet providers where they are, that not all participants in our models are in the same place in their evolution toward value-based care, and we want to grow the base of providers that enter into value-based care arrangements. That may require additional support for things like infrastructure in transforming care. We also expect in the next few years that there will be new models, new cohorts and additional collaboration with our partners in the Center for Medicare on MSSP.”

Proposal to streamline CMS APM portfolio

Officials at CMS have said they are re-evaluating their portfolio of payment models. In its June 2022 report to Congress, the Medicare Payment Advisory Commission (MedPAC) described a potential approach to streamlining and harmonizing Medicare’s portfolio of alternative payment models.

In the report, MedPAC provided specific suggestions to operationalize its June 2021 recommendation that CMS reduce the number of Medicare APMs and design models to work better together. The proposed population health-based approach would reduce the number of ACO model tracks from seven down to a smaller number of tracks that could each be geared toward provider organizations of different sizes and involve different degrees of financial risk.

MedPAC noted that the presence of multiple alternative payment models operating concurrently can create unnecessary complexity and may dilute incentives when Medicare beneficiaries are attributed to more than one model simultaneously and/or when providers participate in more than one APM at the same time.

In its June 2021 report to the Congress, MedPAC recommended that CMS reduce the number of Medicare APMs it operates and design models to work better together when combined. In particular, to reduce the complexity of CMS’s offerings, the Commission said it supports reducing the number of population-based payment model tracks available to providers.

Oregon, California seek to addresses affordability

Besides the changes at CMS, there was quite a bit of activity on the state level in 2022 as well. Several states are using their 1105 Medicaid waivers to begin paying managed care organizations to address social determinants of health such as housing, in tandem with shifts away from fee for service payments. Oregon and California joined the states already pioneering global budget models. Speaking at the March 7 meeting of the federal Physician-Focused Payment Model Technical Advisory Committee (PTAC), Chris DeMars, M.P.H., of the Oregon Health Authority described Oregon’s vision for multi-payer reform that includes three main initiatives: a healthcare cost growth target, spreading value-based payments across all payers and providers, and plans to pilot a regional multi-payer global budget.

To address its affordability crisis, the governor and Legislature of California worked together to create the Office of Health Care Affordability (OHCA). In July, when California enacted its legislation that involves setting cost targets, it became the 10th state attempting to rein in healthcare costs in this manner.

Elizabeth Landsberg, director of the California Department of Health Care Access and Information, which oversees OHCA, explained that OHCA is charged with delivering on three key tasks.

Speaking during a Nov. 30 webinar put on by the California Health Care Foundation, Landsberg said, “First, OHCA will analyze data on healthcare cost drivers. Where are the big increases happening? Second, monitoring to track the future growth in healthcare costs. OHCA will set targets defining acceptable growth, and it has the authority to enforce these targets. Finally, assess market consolidation, a key driver of healthcare costs,” she said. “OHCA also is charged with setting and enforcing targets that are designed to increase primary care and behavioral health investment, promote, value-based payment and help ensure that California has the healthcare workforce to meet the needs of 40 million Californians.”