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AMGA: Link Spending, Quality Performance for True Value-Based Care

CMS should use quality measures that are outcome-based and correlate spending and quality performance to truly assess value-based care, AMGA advised.

Value-based care, quality performance, and outcome measures

Source: Thinkstock

By Jacqueline LaPointe

- In response to a Request for Information from the Assistant Secretary for Planning and Evaluation (ASPE), AMGA recently called on CMS to “define value in a meaningful way” to ensure value-based care models incentivize providers to improve outcomes relative to healthcare spending.

“AMGA knows that value-based care has the potential to drive improvements in patient outcomes,” stated Jerry Penso, MD, MBA, AMGA President and CEO. “But for value to be truly meaningful, Medicare needs to measure for results.”

The industry group argued that CMS does not currently assess for value because the federal agency evaluates cost and quality performance separately.

For example, CMS does not effectively link shared savings payments under the Medicare Shared Savings Program (MSSP) with quality performance, the group explained. MSSP accountable care organizations (ACOs) that earned shared savings in 2016 did not achieve higher quality scores than ACOs that did not qualify for the incentive payment.

The organizations did not even generate higher quality scores than MSSP ACOs that owed shared losses to CMS.

READ MORE: Exploring Quality Measures Under Value-Based Purchasing Models

The new Merit-Based Incentive Payment System (MIPS) under MACRA’s Quality Payment Program also uses this methodology. The program scores eligible clinicians on quality and cost performance independently.

AMGA pointed out that CMS fails to effectively measure value in value-based care models because the federal agency relies on process measures, rather than outcome measures. A 2017 World Economic Forum report stated that only 7 percent of almost 2,000 quality indicators used by the Agency for Healthcare Research and Quality’s (AHRQ’s) National Quality Measures Clearinghouse were outcome measures.

CMS Administrator Seema Verma stated in an October 2017 announcement of the Meaningful Measures initiative that CMS “aims to focus on outcome-based measures.” She elaborated that “how we define value and quality today is a problem” because providers face varying quality reporting rules by payer and it is unclear if quality measures used actually enhance patient outcomes.

AMGA suggested that CMS partner with the International Consortium for Health Outcomes Measurement (ICHOM). The consortium developed 22 standard outcome measure sets that cover about one-half of the global disease burden.

The federal agency should also develop and implement patient-reported outcome measures, AMGA recommended. Patient-reported outcome measures would not only align with a meaningful definition of value that moves away from process measures, but the measures would “improve access to and the quality of information that Americans need to make informed healthcare decisions, including data about healthcare prices and outcomes, while minimizing reporting burdens on affected plans, providers, or payers,” as the ASPE’s Request for Information stated.

READ MORE: Best Practices for Value-Based Purchasing Implementation

Additionally, AMGA stated that CMS can add value to its various programs by allowing the different payment models to compete.

Medicare operates three primary payment systems. The systems are fee-for-service, Medicare Advantage, and ACO models. Each model has its own set of rules and reimbursement policies, as well as its own methods for incenting providers to deliver high-value care.

The siloed Medicare payment systems create an unnecessary burden on all healthcare stakeholders. CMS must perform additional rule-making to address each program and providers must spend more time reading and understanding the additional rules.

As the ACO models grow, CMS must also reconfigure who to incent, how to do so, and how to pay incentive payments, as well as determine which beneficiaries are eligible to participate and how to address when care overlaps with another payment model.

AMGA called on CMS to heed the advice from the Medicare Payment Advisory Commission (MedPAC), which recommended that the federal agency “synchronize” Medicare policies across the three payment systems. CMS can synchronize the programs by aligning financial benchmarks, risk adjustment methodologies, and quality performance rewards.

READ MORE: What Is Value-Based Care, What It Means for Providers?

Aligning Medicare policies would allow the payment systems to compete, incenting the programs to become more efficient. Competition would drive out inefficient programs and plans because individuals would join models that offer affordable, high-quality care.

MedPAC also advised CMS to pay the same on behalf of all Medicare beneficiaries regardless of payment model. Becoming a neutral payer would help beneficiaries select high-value services since beneficiaries would have to pay a higher monthly premium for inefficient programs.

“Having FFS, ACOs and MA compete would align with CMS' goal to pay for value at least to the extent the agency stops paying the costs of lost or missed opportunities,” AMGA added. “Neutral payment would enable the agency to achieve comparable business cases.”

AMGA has repeatedly urged CMS to align its various programs to drive value-based care.

Earlier this month, the industry groups wrote to CMS advising the federal agency to extend the same benefit flexibilities under Medicare Advantage to Medicare Part B alternative payment models. By aligning benefit policies across the Medicare parts, CMS would improve alternative payment model success, thereby encouraging providers to join value-based care models, the group explained.

The group also called on CMS in April 2017 to harmonize Medicare policies across its programs. AMGA urged the federal agency to correlate healthcare cost and quality performance and align Medicare reimbursement policies to reduce administrative burden.

“AMGA members are focused on providing the best care, and variation among CMS programs creates unnecessary impediments,” stated Chester A. Speed, JD, LLM, AMGA Vice President of Public Policy. “Unfortunately, depending on what type of Medicare coverage a patient has, the regulations governing coverage, payment, and quality reporting can vary dramatically. This creates an administrative burden that doesn’t serve the patient, the provider, or Medicare, itself.”

The push to align Medicare programs will ultimately drive value-based care, AMGA contends. Improving the definition of value in healthcare and allowing programs to compete will prompt a meaningful shift to affordable, high-quality care.


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