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CMS Is Considering Making Risk Programs Mandatory. Here’s What You Need to Know

What a wake-up call.

On the heels of the Centers for Medicare & Medicaid Services (CMS) suspending Medicare Direct Contracting for most new applicants and sunsetting the Next Generation ACO model, the new director of the Center for Medicare and Medicaid Innovation (CMMI) last week signaled a likely move toward requiring providers to take financial risk. During an interview with Health Affairs Editor-In-Chief Alan Weil, Elizabeth Fowler, also deputy CMS administrator, announced that CMS is exploring making some alternative payment programs (APM) for Medicare and Medicaid mandatory for providers.

“We are at a crossroads in value-based care,” Fowler told Weil. “It’s become more comfortable to stay in fee for service.”

However, as the single largest payer of medical services, CMS is determined to alter the status quo. CMS “is in a unique position to be a health care disrupter and driver for change and we take this responsibility very seriously,” Fowler said.


New focus for CMMI

After 10 years of APM experience aimed at transitioning from volume to value, CMMI under the Biden Administration has been reviewing its many demonstration programs and has found voluntary models are largely not working to drive health system transformation and achieve cost of care savings at the health care system level.

Going forward, CMMI is shifting to a paradigm “where the patient is the center of the system and that means shifting from a system focused on payments and providers to people,” she said. It includes “clearing a path for innovators and pushing laggards.”


New KPIs

In the past, CMMI judged success on the percent of providers participating in APMs or percent of dollars in alternative payments, Fowler said. Now, it will be focused on ensuring every patient is in “a care relationship that includes a meaningful accountability for quality and total cost of care.”

What does this mean for providers, payers and patients?


Providers need to accelerate pop health expertise and ability to prove success

Those that have not yet built the infrastructure to provide value-based care must make it a strategic imperative. As part of effectively managing a population, providers will be expected to minimize health inequities while also undertaking financial planning and modeling necessary to track total cost of care and thrive with upside and downside risk.

  • Data and analytics will be key to collecting, reporting and using historic and real-time information to address health disparity.
  • New models will include standards of care based on patient acuity as a way to reward providers that reach more patients in need.
  • Expect an increased focus on social determinants of health and the need to partner with community resources that handle concerns outside of strictly clinical needs.
  • CMMI is moving to address the impact that patients play in value-based care, i.e., their willingness, resources and/or ability to follow clinical orders and directives.


Payers will see more opportunity to participate

In order to accelerate the shift to value-based care, CMMI sees other payers playing a bigger role.

  • CMMI wants to make it easier for state and private payers to participate in programs, recognizing current requirements
    are difficult to meet.
  • The goal of Primary Care First is to encourage more payers to participate and get all payers moving to value-based care
    at the same speed.
  • Payers will need the ability to perform financial modeling that includes all program requirements and monitor program
    and/or contract terms.
  • Payers are key to addressing health inequities, especially the capability to test and scale inequity in each payment model.
  • Stakeholders will need to be actively removing friction for patient access.


Patients can expect more programs focused on care management and health equity

CMMI wants all patients to have a care relationship that includes accountability for quality and cost of care. Providers and payers should plan to:

  • Meet patients where they are, opening more options for access to care, including
    • Telehealth
    • Behavioral health
    • Community resources
  • Remove barriers to health equity
  • Look beyond just health needs to support and empower patients to self-care.

With CMS determined to put patients at the center of the health care system, it will be judging success at least in part on metrics that matter to patients, said Fowler. Delivering a good patient experience and outcomes will continue to be factored into provider risk contracting.

While CMMI has not announced specific programs yet to incorporate these priorities, providers and payers cannot afford to ignore the clear direction from CMS. It is doubling down on managed care, with mandatory programs in the offing. Providers will be required to accept increasing responsibility for quality and cost for populations, including underserved communities and people.


For more information on how to succeed with value-based payment arrangements with CMS, please contact us at info@copehealthsolutions.com

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