Biden’s CMMI signals new priorities for value-based payments

The Center for Medicare and Medicaid Innovation will take a closer look at cost-based payment models, with CMMI COO John Blum noting that full-risk models could lead to federal agency overpayments and punish providers with more vulnerable patient populations.

“I don’t think CMS will promote high-risk models just for the sake of taking more risks,” Blum said at the National Association of Accountable Care Organization conference on Thursday.

While the comments were vague, the implications could be overwhelming – they could signal that CMMI is seeking to restructure payment models to combat inappropriate coding, to shift the focus of cost-based programs to reduce patient inequality, and reduce initiatives that only serve give dominant suppliers large market shares, ”said Dr. Mai Pham, former head of CMMI.

“Providers, if motivated by a risk budget or other incentive, can get creative with programming,” said Pham, who is currently CEO of the Institute for Exceptional Aid, which works to improve care for people with intellectual and intellectual development. developmental disorders.

Fan said as CMMI develops new payment models, the organization will be attentive to proposed incentives and consider how risk adjustment programs incentivize doctors and health insurance plans to enroll patients as sick so they can receive more reimbursement.

This direction represents a sharp departure from the previous administration, which “put risk first,” said Anders Gilberg, senior vice president of government relations at the Medical Group Management Association. This approach ultimately stalled efforts to promote value-based care across the country, as independent practitioners and small medical groups built around a payment-for-service system were unable to make the capital investment needed to shift their activities to focus on cost.

During the Trump administration, Gilberg said some healthcare providers simply refused to participate in accountable healthcare programs.

“Those that were successful tended to cluster in areas with richer practice and perhaps less economically and racially diverse areas,” he said.

As an example, Gilberg pointed to Paths to Success Program, which required new accountable care organizations to accept the risk of worsening after three years of participation – much faster than Medicare’s general savings program, which launched the ACO program as part of the Affordable Care Act. The aggressive risk associated with this reportedly discouraged new entrants from participating in the model, with only 35 ACOs enrolled in 2020, up from an average of 107 in 2018, according to the National Association of Accountable Care Organizations.

“When half of the patients are at risk and the other half are paid for services, it creates competing incentives,” Gilberg said. “The bottom line is that he wants to conform to practices that fit the spectrum of risk.”

Full risk adjustment models that exclude some providers excluded some patients.

The participation of doctors in environmental protection is lower in places with more vulnerable populations than in wealthier communities, which limits the access of vulnerable groups to these doctors, which can exacerbate existing disparities in the quality of health care. According to the ACO, about 36% of primary health care providers working with zip codes with the lowest proportion of blacks participated in the ACO, while only 26% of doctors working with zip codes with a high proportion of blacks participated in the ACO. … Health Report 2016.

“The specter of inequality looms over these payment models,” said Dr. Joshua Liao, medical director of payments strategy at the University of Washington School of Medicine.

Multipayer models, designed with both private and Medicare payers in mind, help physicians simplify risk acceptance by allowing physicians to align incentives for many large patient populations and to simplify the structure of their operations.

“If half of my patients are Medicare and 30% are commercial payers, then if they are in the joint program, I can make 80% changes,” Liao said. “This increases the likelihood that changes in care could affect more people.”

Source link

Leave a Reply

Your email address will not be published. Required fields are marked *

Back to top button