Key Plans for Advancing Accountable Care, Value-Based Payment

November 14, 2022 - Accountable care is getting a makeover. For over a decade, the healthcare system has been making the shift to accountable care, or “the coordinated provision of patient services by healthcare providers and facilities with the goals of improving patient and system outcomes and avoiding inefficiencies.” However, recent advancements in value-based care and payment are necessitating a new definition.

Mark McClellan, MD, PhD, director of the Duke-Margolis Center for Health Policy and Robert J. Margolis professor of business, medicine, and policy at Duke University, shared the new definition of accountable care at the Health Care Payment Learning and Action Network (LAN) Summit last week.

“Accountable care is care that centers on the patient and aligns a care team to support shared decisionmaking and helps realize equitable, comprehensive, high-quality, affordable, longitudinal care,” said McClellan, who also serves as LAN co-chair.

LAN came up with the new definition after receiving feedback from healthcare stakeholders making the transition from fee-for-service to value-based payment. It is still a mouthful, McClellan admitted, “but it recognizes that the care team must be supported in going beyond traditional medical services to improve outcomes and improve equity.” The updated definition also acknowledges “that accountable care requires payment reform to sustain these person-centered care approaches.”

Data released at LAN Summit revealed that almost 20 percent of healthcare payments from major public and private payers are risk-based, while another 40 percent are tied to quality and value. Nonetheless, progress toward value-based care payment has been slow, albeit steady.

The economics behind value-based care has been a major focal point of the LAN over the last couple of years. However, fellow LAN Summit speaker Frederick Isasi, JD, MPH, executive director of the nonprofit, nonpartisan healthcare advocacy organization Families USA, said that the new definition adds “an emphasis on the actual people and patients that alternative payment models service and the outcomes [patients] should experience.”

“We are broadening our focus and recognizing that it takes more than just a financial arrangement to achieve accountable care,” Isasi highlighted.

Isasi, McClellan, and other industry leaders convened key stakeholders, including CMS Innovation Center (CMMI) leaders, to uncover the path forward for this new idea of accountable care and the value-based payment models behind them.

CMMI’s roadmap to accountable care

Like LAN, CMS’ innovation arm has undergone a refresh after years of experimenting with value-based payment models. CMMI revealed last year that it has a new strategy for developing and testing alternative care delivery and payment models. The new strategy focuses more on priorities, such as advancing health equity and driving innovation, through accountable care.

CMMI’s definition of accountable care at that time focused on “a patient being in a care relationship with a provider that is accountable for quality and total cost of care,” Chief Strategy Officer, Purva Rawal, PhD, said at LAN Summit. But this year, CMMI wants “to step further to describe how patients should hopefully experience accountable care relationships in which their doctors and other healthcare providers are working together and with them to manage their overall health, including physical, behavioral, and social needs.”

To achieve this, Rawal said CMMI is “focused on designing and testing models that bring advanced primary care to more beneficiaries.” One way this will happen is through more accountable care organization (ACO) programs. CMMI’s recent report highlighting the implementation of its new strategy also states that the agency is looking to develop specialty-focused models, execute strategies to integrate specialty and primary care in model design, reexamine ACO benchmarking approaches, and identify ways to measure accountable care.

In the near future, according to the report, accountable care will look like more advanced primary care tests, state total cost of care model demonstrations, population- and condition-specific models, population health-focused bundled payments, and prescription drug models. Beyond 2025, CMMI also plans for more ACO models that support primary care and specialty integration models.

“Accountable care is about putting people at the center of their care, holistically assessing their needs and coordinating the care they need to thrive,” CMS Administrator Chiquita Brooks-Lasure said in a separate panel at the LAN Summit. “Accountable care must start and end with people getting high-quality care.”

Accounting for specialty care

Primary care providers have been considered the quarterbacks of accountable care. These providers have been the center of care coordination and the captains of managing outcomes and total cost of care. This model has served population-based models particularly well, and public and private payers certainly plan to advance primary care in the name of accountable care. However, its future and that of value-based payment must also include specialty care, industry leaders agreed at the LAN Summit.

“As the strategic refresh turns its focus towards improving specialty care, we expect these accountability structures to coordinate with or more fully integrate specialty care to deliver whole-person care for Medicare and Medicaid beneficiaries,” said Sarah Fogler, PhD, MA, acting director of the Patient Care Models Group at CMMI.

CMMI models like the Bundled Payments for Care Improvement (BPCI), its Advanced Iteration, and the Comprehensive Care for Joint Replacements (CJR) have focused on inpatient medical and surgical admissions, as well as procedures in hospital outpatient departments, and improved care transitions, Fogler continued. Now, there is an opportunity to address “fragmentation around primary care providers and specialists” and “increasing access to high-quality specialty services.”

To include specialists in accountable care, Fogler said there will be more data sharing to improve transparency around clinician performance, deploying bundled payments that align with primary care, embedding specialty care in primary care, and creating incentives within population-based models to encourage specialty care integration. The latter—also a longer-term goal for CMMI—would leverage approaches like beneficiary attribution and subpopulation targets to incent accountable specialty care.

However, addressing specialty care’s role in accountable care models can be as simple as pulling up a seat to the value-based table, according to Rawal.

“When we think about the future of ACOs and how we incorporate non-primary care providers, whether ancillary providers or specialists, there are three key themes to keep in mind: open communication, collaboration, and transparency,” Rawal stated.

Multi-payer alignment key to advancement

Value-based care progress is limited when commercial payers, Medicaid, and Medicare are not pushing in the same direction. That is something Liz Fowler, PhD, JD, CMS deputy administrator and director of CMMI, hears from healthcare stakeholders a lot.

Multi-payer alignment in the realm of accountable care is now a major theme for CMMI as it develops and tests new alternative care delivery and payment models. Right now, though, the industry is at a “foundational stage” when it comes to aligning Marketplace plans, admitted Ellen Lukens, MPH, CMMI deputy director.

CMS has urged Marketplace payers through its annual notice to issuers to engage in alternative payment models, such as those run by CMMI. Lukens said the agency is also working on quality metrics and ratings that align across the Centers at CMS to “make sure that we have a stronger signal across those plans.”

Aligning quality metrics across payers will be key to advancing alternative payment models that incentivize accountable care.

“We want to see where there are opportunities to align across our programs because that’s when you can really drive change,” stated Meena Seshamani, MD, PhD, deputy administrator and director of the Center for Medicare. Providers have a better idea of where to invest to change workflows, implement team-based care, and other accountable care strategies when people are rowing in the same direction, Seshamani explained.

Across the different parts of CMS, the federal government is working on aligning quality measures and making sure those measures matter. Lukens, for example, shared how the agency is thinking about measures around access to care, particularly as it related to health equity, another pillar in CMMI’s new strategy. The agency is also seeking ways to align data collection in order to aggregate more accurate information including on race and ethnicity.

“The whole is greater than the sum of its parts,” Seshamani said. “To be able to have things more streamlined and aligned can really reap dividends in terms of being able to galvanize change on the ground to improve the healthcare system.”

The next generation of value-based payment models aims to integrate specialty care and align models across payers. Not only do these goals advance accountable care as it relates to “equitable, comprehensive, high-quality, affordable, longitudinal care” as the new definition states but they also attempt to take the burden off of providers so they can put the patient first.

Delivering accountable care through value-based payment models has not been easy for providers. They have encountered myriad challenges, including those administrative in nature as well as out of their control. With a new definition of accountable care, CMS is leading a new strategy to achieve truly value-based care.