Two Value-Based Care Initiatives That Could Shift the Alternative Payment Model Landscape [Sponsored]

Dementia or brain damage and injury as a mental health and neurology medical symbol with a thinking human organ made of crumpled paper torn in pieces as a creative concept for alzheimer disease.Dementia or brain damage and injury as a mental health and neurology medical symbol with a thinking human organ made of crumpled paper torn in pieces as a creative concept for alzheimer disease.

The Centers for Medicare and Medicaid Services has announced two initiatives set to launch in July 2024 that could help move the needle away from fee-for-service payments. One focuses on supporting family caregivers of dementia patients to forestall their admission to a nursing home and the considerable costs that accompany that decision. Another makes it easier for small primary care practices with no prior experience to pursue bundled payment plans over a 10-year period. Both are ambitious pilot programs which could have a significant impact on healthcare delivery.

Value-based care and alternative payment models will be an important topic at the upcoming HLTH event at the Las Vegas Convention Center October 8-11. The Wild Wild West of Medicare Advantage panel will take place Monday, October 9 from 3-3:40 pm PT. This year marked a milestone for Medicare Advantage plans, which added more members to overtake Medicare for the first time. But the innovative payment models and expanded coverage options of MA plans have led to upcoding and overpayments, and the government is beginning to crack down. In this panel, moderated by Erin Trish, co-director, Schaeffer Center for Health Policy & Economic USC Schaeffer Center for Health Policy & Economics, Rick Gilfillan MD, a consultant, and Sachin Jain MD, CEO of SCAN Group and SCAN Health Plan, will discuss the merits and challenges of Medicare Advantage. 

The Medicare Management Balance Beam is scheduled for Tuesday, October 10 from 11:50 am to 12:30 pm PT. Medicare plans are constantly walking the fine line between cost containment and maintaining accessibility and quality of services. Can they maintain this balance? Among the speakers for the session are: Debra Richman, Chief Development Officer, The Oncology Institute (moderator) with Anna de Paula Hanika, CEO and co-founder of Uno Health, and Dr. Sree Chaguturu, Chief Medical Officer, CVS Health.

To learn more about the agenda and to register, click here.

The process of shifting the health system from one based on fee-for-service to one supported by value-based payment structures has been slow but steady. As of November 2021, alternative payment models accounted for 20% of all healthcare payments. Those include bundled payments, population-based payments, fee schedule payments with accountability for performance.

Guiding an Improved Dementia Experience (GUIDE) seeks to address the complications caregivers face helping a loved one with deteriorating cognitive functions and give them support they lack. The number of Americans who currently live with Alzheimer’s disease or another form of dementia is estimated at 6.7 million and is projected to grow by nearly 14 million by 2060. The eight-year model will be offered nationwide, open to participation by Medicare Part B providers and suppliers. In return for their participation, providers receive monthly payments (per beneficiary, per month). They may also bill for respite care services, and are eligible for one-time payments to support infrastructure, according to Mintz blog post penned by Of Counsel Rachel Yount. The initiative includes eight components, according to data from CMS:

  • Separate assessments for beneficiaries and caregivers to identify their needs and a home visit to assess the beneficiary’s safety.
  • Care plans are provided to beneficiaries that address their goals, preferences, and needs, which helps them feel certain about next steps.
  • Caregivers and beneficiaries can call a member of their care team or a third-party representative using a 24/7 helpline.
  • Care navigators provide long-term help to beneficiaries and caregivers so they can revisit their goals and needs at any time and are not left alone in the process.
  • The beneficiaries’ care navigators connect them and their caregivers to community-based services and supports, such as home-delivered meals and transportation.
  • Caregivers take educational classes and beneficiaries receive respite services,
    which helps relieve the burden of caregiving duties.
  • Clinicians review and change medication as needed. Care navigators
    provide tips for beneficiaries to manage the medication schedule.
  • Beneficiaries receive timely referrals to specialists to address other health issues, such as diabetes, and the care navigators coordinate care with the specialist.

To qualify for the program, healthcare providers will need interdisciplinary teams consisting of care navigators with training in dementia assessment and care planning. Clinicians need to demonstrate proficiency with dementia and have specialty backgrounds in psychiatry, neurology, geriatric medicine, geriatric psychology, behavioral neurology or geriatric neurology. The application period kicks off next month.

A new primary care alternative payment model, Making Care Primary (MCP) seeks to improve health equity for Medicare and Medicaid beneficiaries. It will be piloted in eight states: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina and Washington state. The providers will consist of small, independent primary care practices. They are not required to have prior experience with value-based care.  One of the goals of the 10.5 year program is for participants to use the experience they gain in the first few years of the program when they partner with specialists and social service providers to implement care management services, and screen for behavioral health conditions, to progress to more financial incentives the more effective they become in supporting value-based care.

For the past few years, CMS has struggled to coax more physician practices to embrace alternative payment models. Although Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) sought to incentivize physicians to move into new value-based payment models, testimony to a U.S. House Subcommittee in June by the Medical Group Management Association explained why physicians are reluctant to adopt alternative payment models and what can be done to improve this. The Association has more than 60,000 members including medical practice administrators, executives, and leaders at 15,000 medical practices spanning small private medical practices to large national health systems. Among MACRA challenges cited in the testimony by Anders Gilberg, MGA
senior vice president, government affairs are:

  • Excessive reporting requirements
  • Inadequate alternative payment model participation options
  • Physician payments have not kept up with inflation or the cost of running a medical practice.

Gilberg recommended providing physician practices access to upfront resources, investments, and tools to succeed in an alternative payment model.

Hopefully, these two new CMS initiatives will pave the way to wider adoption of alternative payment models while integrating physician practice needs in the process. Dementia in particular is a condition that poses unique challenges, not only to the individual but to their families as well as hospitals and nursing homes. It can affect the family in so many different ways that other chronic conditions that alternative payment models have focused on do not. The MCP initiative has embraced the need for more flexible solutions and mentoring for alternative payment models to succeed. It will be interesting to see whether these programs can improve patient outcomes and manage costs.

Value-based care and alternative payment models will be an important topic at the upcoming HLTH conference at the Las Vegas Convention Center October 8-11. To learn more about the agenda and to register, click here.

Photo: wildpixel, Getty Images