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Healthcare providers welcome changes to CMMI, back flexibility

ACO and hospital executives say they want greater flexibility in models for Medicare, Medicaid and dual-eligible patients.

Susan Morse, Managing Editor

Accountable care organizations say they support the Centers for Medicare and Medicaid Services' request for proposals for feedback on changes to CMS's innovation center that would allow for more flexibility in existing payment models.

Further, the support seems widespread whether the health systems made or lost money with Pioneer ACO, an accountable care organization model that has been transformed into the Next Generation ACO model.

New York-based Montefiore had success with Pioneer and now with Next Generation, said Kirstin Mooney, assistant vice president of regulatory and legislative policy at the health system.

"Our five-year experience has been really, really positive," Mooney said. "We used it as an opportunity to engage physicians through the community, and quality scores increased."

Though the health system made significant investments to design infrastructure to the models, Mooney does not see CMS making a radical change that would pull the rug out on providers in existing models. Instead, she believes CMS will let existing models sunset before making changes.

"It's a slightly different lens, a slightly different focus, but the expectation is the same, the goal is the same," Mooney said, referring to value-based care. "It certainly presents a really good opportunity."

Montefiore made the commitment a few years ago to getting to a million lives in value-based care. The health system currently has 400,000 patients in value-based models, including 100,000 in Medicare through Next Generation and 170,000 in Medicaid through arrangements with health plans.

[Also: CMS says it will change direction of CMMI, wants providers to have greater flexibility in payment model design]

Montefiore is also in bundled payments and the oncology care model and has value-based models outside of Medicare.

Mooney sees a good opportunity in CMS's stated aim to focus on the Medicaid population, and she'd like to see more done on models for dual-eligibles.

"What is true in the Bronx, Medicare Advantage has a high penetration rate," Mooney said. "One of the exciting things is a focus on that population, to expand that."

On the other hand, Maine-based Beacon Health lost money in Pioneer and Next Generation.

Beacon paused Pioneer, in 2016 and entered into Next Generation. It also had a Medicare Shared Savings Program, according to CFO Jeff Sanford.

"For 2016 and 2017, we had put critical access hospitals into an MSSP and larger hospitals into Next Generation," he said. "We did not do well in those models."

Sanford believes Next Generation, in particular, may favor the demographics of larger, urban health systems.

Sanford is encouraged by what he's heard from CMS Administrator Seema Verma about new models.

"To hear that CMMI is retooling, we're definitely interested in that," Sanford said. "I like the idea of increased flexibility around waivers, that's clearly an interesting opportunity."

Beacon has been working with a post-discharge home waiver for Medicare patients in its ACO. But they would like to have that waiver for all Medicare patients, Sanford said.

"This waiver allows us to have a nurse or social worker do a home visit within 10 days of discharge," he said.

The home visits can determine whether the patient has food, transportation, heat or a social network, he said.

[Also: CMS announces 45 ACOs are now participating in Next Generation model]

"There's waivers available, but you can only do it for ACO patients, you can't do for all Medicare patients that aren't in the ACO," Sanford said. "It's that kind of flexibility ... we could use even more."

CMS's request for proposals to change models out of the Centers for Medicare and Medicaid Innovation Center has an emphasis on easing the physician reporting burden.

CMMI is interested in increasing the availability of specialty physician models to engage specialty physicians in alternative payment models, especially for independent physician practices, CMS said.

Tom Price, director of the Department of Health and Human Services, is a physician who has long opposed mandatory bundled arrangements.

"The new administration wants to ensure independent physician practices have an opportunity to succeed in MACRA," said Yulan Egan, senior consultant for research at the Advisory Board. "They've definitely been more explicit to reaching out to physicians in particular."

CMMI will look to reduce the administrative complexity of quality reporting, the reporting of different metrics to each payer and the complex way performance is measured, Egan said.

In MACRA, CMS will want to make it easier for physicians to apply for the advanced alternative payment model track that has a heavy reporting burden but greater payments, she said.

The downside is any uncertainty over canceled programs, such as when CMS changed the mandatory bundled payment models.

"We're going to continue to see experimentation around ACOs," Egan said. "For providers which have made investments, there's uncertainty. Even though it's not a complete 180, they will scale back."

But, she said, "For those participating in programs, CMS will hear loud and clear providers want to continue down the path."

The American Hospital Association said hospitals and health systems are fully committed and engaged in the ongoing transformation from a volume-based to a value-based care system. 

"As this transition moves forward, the AHA will continue to work with Secretary Price, Administrator Verma, and others at HHS to give hospitals the opportunities, flexibility, and predictability they need to improve care coordination and efficiency and deliver better value for their patients and communities," said Joanna Hiatt Kim, vice president of payment policy at the AHA, in an emailed statement.

CMS said the innovation center will approach a new model design focused on, among other factors, voluntary models with defined and reasonable control groups or comparison populations.

It will look to reduce burdensome requirements and unnecessary regulations to allow physicians and other providers to focus on providing high-quality healthcare to their patients.

It will also look to have choice and competition in the market and use data-driven insights to ensure cost-effective, quality care.

Smaller scale models will be tested in eight focus areas including increased participation in advanced alternative payment models, consumer-directed care and market-based innovation models, physician speciality models, prescription drug models, Medicare Advantage innovation models, state-based innovation models, including those that are Medicaid-focused, mental and behavioral health models, and also program integrity.

There will be a focus on key payment interventions rather than on specific devices or equipment. 

There will also be expanded opportunities for participation in advanced APMs.

CMS also seeks guidance on ways to capture appropriate data to drive the design of innovative payment models and strategies to incentivize eligible clinicians to participate in advanced APMs.

CMS may develop models to facilitate and encourage price and quality transparency, including the compilation, analysis and release of cost data and quality metrics that inform beneficiaries about their choices. 

For example, beneficiaries could choose to participate in arrangements that would allow them to keep some of the savings when they choose a lower-cost option, or that incentivize them to achieve better health, CMS said.

Testing includes allowing Medicare beneficiaries to contract directly with healthcare providers, having providers propose prices to inform beneficiary choices and transparency, offering bundled payments for full episodes of care with groups of providers bidding on the payment amount and launching preferred provider networks.

One potential option may be to include specialty physician management of a defined population of beneficiaries with complex or chronic medical conditions, including multiple chronic conditions. 

This may include the specialist serving as the primary source of care and providing care coordination for medically complex beneficiaries.

Another option may be paying healthcare providers for limited episodes of care based on quality measure performance and competitive pricing.

For cancer care, in particular, a model could test full prepayment for Medicare and Medicaid beneficiaries, with care provided in collaborative networks, possibly incorporating elements from the existing oncology care model, CMS said. 

MACRA created the physician-focused payment model technical advisory committee. Price may choose to recommend innovation center testing of models recommended by PTAC, CMS said.

CMS also wants to test new models for prescription drug payment, in both Medicare Part B and Part D and state Medicaid programs.

Models that contemplate novel arrangements between plans, manufacturers, and stakeholders across the supply chain, including, but not limited to innovative value-based purchasing arrangements, and models that would increase drug pricing competition while protecting beneficiaries access to drugs are of particular interest, CMS said.

CMS is currently implementing an MA plan model, the Medicare Advantage Value-Based Insurance Design model, that provides benefit design flexibility to incentivize beneficiaries to choose high-value services. This model could be modified to provide more flexibility to MA plans and potentially add additional states.

CMS is potentially interested in a demonstration in Medicare Advantage that gives incentives to MA plans to compete for beneficiaries, including those beneficiaries currently in Medicare fee-for-service.

Models specific to Medicaid populations are also being considered.

CMS is actively exploring potential models focused on behavioral health, including focus areas such as opioids, substance use disorder, dementia, and improving mental healthcare.

CMS is also seeking comment on ways that may reduce fraud, waste, and abuse and improve program integrity.

Twitter: @SusanJMorse
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