Maryland Stakeholders Express Hopes, Concerns About AHEAD Model
Next year the State of Maryland will transition from its unique Total Cost of Care (TCOC) payment model to the CMS AHEAD (States Advancing All-Payer Health Equity Approaches and Development) model. The state’s Health Services Cost Review Commission (HSCRC) recently heard testimony from a variety of stakeholders about their hopes and concerns for AHEAD.
Under a total-cost-of-care approach, a participating state uses its authority to assume responsibility for managing healthcare quality and costs across all payers, including Medicare, Medicaid, and private coverage. States also assume responsibility for ensuring health providers in their state deliver high-quality care, improve population health, offer greater care coordination, and advance health equity by supporting underserved patients.
The AHEAD Model will provide participating states with funding and other tools to address rising healthcare costs and support health equity. But the model also holds states accountable for state-specific Medicare and all-payer cost growth and primary care investment targets, and for population health and health equity outcomes.
States participating include Maryland, Connecticut, Hawaii, Vermont, New York (in five downstate counties) and Rhode Island.
In her testimony, Sarah Szanton, Ph.D., M.S.N., dean of the Johns Hopkins School of Nursing, advocated for increased investment in community-based interventions that can bridge critical gaps in the health system and relieve pressures on hospitals. She gave an example of a neighborhood nursing program that connects residents with registered nurses and community health workers to provide home-based care, chronic disease management, social support, reducing emergency visits and hospitalizations while improving health and well being. “It provides seven times the return on investment, but current payment structures do not adequately support these programs,” Szanton said. She urged the commission to consider investments that make these programs accessible to all Marylanders, regardless of payer or provider, to create a healthcare system that is not only cost-effective, but also equitable and patient-centered through AHEAD. She encouraged implementation of flexible funding models like shared savings or pooled funds to scale proven interventions statewide.
John Chessare, M.D., M.P.H., CEO of the Greater Baltimore Medical Center (GBMC), suggested the state needs more resources applied to the creation of accountable care organizations. “We have an opportunity to better fund multi-specialty group practices and accountable care organizations to get the work done,” he said. But just adding more revenue to the system does not improve the value equation, he added. “The state has an opportunity to free up resources to drive better value by funding accountable groups of clinicians, as has happened in the Midwest pretty successfully with accountable care organizations to drive better access, better accountability, better partnerships with patients.”
Chessare also suggested the state work to improve the transition from inpatient to post-acute care and to create a better palliative medicine system. “Maryland is 35th in the nation in the use of hospice, and we absolutely believe it's because the conversations are happening way too late, and people are suffering needlessly because in the interim between chronic illness, frailty and death, they are not getting the benefit of palliative medicine and its ability to relieve symptoms,” he said.
Tyler Blanchard, M.B.A., market president of value-based care physician enablement company Aledade, advocated for a model that balances the upfront funding of AHEAD with the outcome-driven incentives of the Medicare Shared Savings Program. “We applaud the direction that the multi-payer model is going in with AHEAD to bring in Medicaid,” he said. “We really see a big opportunity in the commercial space to be better aligned. There are value-based care programs in the commercial space in Maryland, which is great, but they are currently not very aligned in terms of quality measures, reporting processes and payment mechanisms, attribution methodology, so it's challenging for primary care providers to participate in multiple models with different payers and keep track of all those details.”
Steve Leonard, Ph.D., M.B.A., is president and CEO of TidalHealth, the largest tertiary referral hospital on the rural eastern shore of Maryland. He said the frustration level is high when contemplating the inequity of the total-cost-of-care model for rural hospitals. “If there needs to be a significant evolution of where resources are applied by this commission, you need to be investing in resources in areas where population growth is happening, and reduce costs in areas where there is contraction,” he said. “We need to support unique rural tertiary centers like ours and narrow the funding gap between high-cost and low-cost hospitals.”
The HSCRC’s written summary of the meeting noted that Brent Berger, M.D., president of the Montgomery County Medical Society, "expressed concerns about the impact of cost containment efforts on healthcare quality and access in Maryland. He fears the AHEAD model will exacerbate these issues, highlighting two primary threats: inadequate community-based primary and behavioral physician care, and reduced access to innovative hospital care due to cost containment. He emphasized the lack of a coordinated effort to address these deficiencies, particularly the shortage of primary and specialty care physicians, which leads to increased emergency room visits and hospitalizations.”
The report said that Berger pointed to Maryland's challenging private payer environment, dominated by CareFirst, as a significant driver of physician shortages. “He cited low commercial insurance payments, burdensome prior authorizations, and recruitment difficulties as factors contributing to Maryland's reputation as a difficult state to practice medicine. He argued that expanding the scope of practice for advanced practice professionals is not the solution and instead recommended greater collaboration and financial support between hospitals and community physicians to enhance care transitions and population health.”
