Biden Administration Pauses Key Value-Based Reimbursement Models

March 10, 2021 - The Biden administration has paused several prominent value-based reimbursement models run by the CMS Innovation Center (CMMI) to review model details, according to several updates provided on model webpages.

Among the value-based reimbursement models impacted are the Geographic Direct Contracting Model, Primary Care First Model’s Seriously Ill Population option, and the Kidney Care Choices Model—three models approved by the Trump administration.

The update on the Geographic Direct Contracting Model and the Primary Care First Model webpages stated that the administration is reviewing the models and will share additional information when it becomes available. For the Primary Care First Model, that also means the Seriously Ill Population model option will not launch on April 1, 2021, as previously announced.

The administration also quietly delayed the Kidney Care Choices Model’s first performance period to Jan. 1, 2022. The model was originally slated to launch on April 1, 2021.

A separate update was also recently provided for the CMS' largest value-based reimbursement model, the Medicare Shared Savings Program, pushing back the application process timeline for accountable care organizations (ACOs) applying to participate starting Jan. 1, 2022. The new deadline is now in August for ACOs to submit participating providers lists to CMS. The previous deadline was in October.*

The Biden administration did not indicate how long CMMI will review the models or whether the models that have yet to launch will do so as planned next year.

But that does not mean the models are on the chopping block, says Michael Abrams, co-founder and managing partner at Numerof & Associates.

“It's natural for the administration to want to take a close look at the programs that are on the verge of being implemented to satisfy for themselves that this is not a disaster in the making where they’ll be left holding the bag for something they did not conceptualize nor approve on their own,” Abrams told RevCycleIntelligence.

These value-based reimbursement models are complex, Abrams added, so the administration will want to address provider concerns, such as potential overlap and patient management, especially in the Geographic Direct Contracting Model.

The Geographic Direct Contracting Model was pushed through last minute by the Trump administration, with CMS announcing the model in December 2020 and opening the request for applications on Jan. 15, 2021.

The model is an extension of CMMI’s latest directing contracting options and ties payments to care provided to beneficiaries residing in a specific area. The model will test whether a geographic-based approach to value-based care will reduce Medicare spending while improving outcomes.

Healthcare industry groups including the National Association of ACOs (NAACOS) have criticized the model though, citing the model’s mandatory beneficiary participation if an individual lives in a direct contracting entity’s (DCE) area.

This concern could be problematic for the new value-based reimbursement model, says Abram.

“Some flags have been raised about the model, it being more complex than anything else, potential overlap, patient management, and the difficulty of trying to explain to patients how it is that they find themselves assigned to a particular program that they never heard of,” Abrams stated.

“You have to take into consideration what it means for the individual patients who are assigned and have not opted into this and you need to minimize the additional burden on them because it's simply not right to make their lives that much more complex by trying to get them to understand what this is all about and what it means for them,” Abrams added.

In light of the concern, some groups have asked CMMI to halt implementation of the model.

The model was initially set to run from Jan. 1, 2022, through Dec. 31, 2024, with another three-year performance period starting Jan. 1, 2025.

The Biden administration has undertaken a review of Trump-era regulations, freezing many last-minute policies and regulation during that time. Some regulations impacted by this effort include several Medicaid waivers allowing the implementation of work requirements and a final rule seeking to streamline prior authorizations.

However, industry experts, including Abrams, do not believe the latest actions of the Biden administration suggest a pullback from the value-based reimbursement transition.

UPDATED 03/10/2021: The article has been updated to clarify the changes to the MSSP application process and that the program is run by CMS, not CMMI.