Accountable care models will be almost universal for Medicare and Medicaid beneficiaries by 2030, CMS leaders say

• A forthcoming revamp of federal value-based payment models will include features designed to boost provider participation, CMS and CMMI leaders said.
• Improved healthcare affordability will be among the pillars of the refreshed strategy.
• Ongoing models won’t end early as part of the new approach, but they may be modified.

Providers can expect more of a nudge into federal value-based payment (VBP) models but also more support in making the necessary adjustments to succeed in those models, according to a new blueprint published Oct. 20 by CMS and the Center for Medicare & Medicaid Innovation (CMMI).

The agencies released a white paper detailing the changes to federal VBP programs that are in store during the Biden administration. Many of the key takeaways echo comments made by CMMI Director Elizabeth Fowler during a presentation Sept. 30 at HFMA’s virtual Thought Leadership Retreat.

One goal of the new approach is to ensure every Medicare fee-for-service beneficiary and most Medicaid beneficiaries are in an accountable care relationship by 2030. That objective will involve bolstering the VBP capabilities of providers across the continuum of care, and the effort can be expected to include critical access hospitals and disproportionate share hospitals.

“We understand that providers need more support,” Ellen Lukens, director of CMMI’s Policy and Programs Group, said during a stakeholder call Wednesday. “Accepting downside risk and meeting model requirements is not easy.”

CMMI thus intends to offer “more actionable data, learning collaboratives and more regulatory and payment flexibility,” she said.

Models will be designed to “minimize selection bias,” Lukens said, although she did not use the word mandatory to describe participation. The white paper states that making models mandatory will be considered as long as any such approach does not hamper providers that care for underserved populations.

Other ways to address selection bias will include improving benchmarking and risk adjustment.

“Historically, complex financial benchmarks have undermined the effectiveness of our models,” Lukens said. “We need to set benchmarks in the future that balance encouraging participation while sustainably generating savings. This will require us to improve testing and analysis of benchmarks and risk adjustment methodologies prior to model launch.”

Adjustments could be in store for current models

Expanding accountable care is one of five broad objectives for VBP models going forward. The four others are:

• Advance health equity
• Support innovation
• Address affordability
• Partner to achieve system transformation

Fowler said Wednesday there are no plans to end ongoing models early as part of the new strategic approach. However, the five goals “will guide revisions to existing models as well as consideration of future models.” For example, current models may be updated to better address the social determinants of health, including through modified financial incentives, or to include more Medicaid beneficiaries.

As Fowler previously said during HFMA’s event, providers can expect a streamlined portfolio of VBP models as part of a more cohesive federal strategy.

“We know from our participants that clarity around key design elements, such as beneficiary attribution and distribution of financial incentives, is really critical,” she said during Wednesday’s call. “In addition to reducing overlap, we want our models to be simpler and easier to participate in, with less administrative burden.”

Efforts to boost cost effectiveness will be central

Improving the affordability of care is one pillar of the new strategy, meaning models will be designed to reduce out-of-pocket costs in addition to Medicare and Medicaid expenditures. “We’ll be looking at strategies that target healthcare prices and reduce unnecessary or duplicative care,” Fowler said Wednesday.

Models can be expected to include metrics showing how many patients forgo care because of cost. As an example of initiatives to reduce waste, the white paper cites progress made through the Bundled Payments for Care Improvement Advanced program to reduce skilled nursing facility use without negatively affecting quality and outcomes. Site-neutral payments will be considered for some models.

With an eye on affordability, CMMI is engaging with stakeholders on how to best integrate specialty care episodes in accountable care models, said Christina Ritter, director of CMMI’s Patient Care Models Group. Episode-based payment will remain an aspect of VBP models even as the focus shifts to total-cost-of-care approaches, she said.

Drug pricing is among the most glaring sources of rising out-of-pocket costs. Although broader policy initiatives will be needed, VBP models likely will tackle the issue as well. Approaches may include outcome-based arrangements with manufacturers, shared-savings programs for providers and bundled payments that cover treatment episodes.

“We are considering small-scale mandatory models that link payment for drugs and biologics to improved outcomes, reductions in health disparities, patient affordability and lower overall costs,” Fowler said.