Practices Push for Quicker Value-Based Purchasing Transition

April 12, 2018 - The Council of Accountable Physician Practices (CAPP) recently urged policymakers to prioritize the value-based purchasing transition by accelerating the shift away from fee-for-service.

“We recognize that much of policymakers’ and the public’s attention is focused on potential changes to our systems of insurance coverage,” the coalition of multi-specialty medical groups and health systems stated in a new report. “While ensuring access to coverage is vital, the payment system that underlies coverage is ultimately the strongest lever available for achieving the triple aim of improving the individual experience of care, improving population health, and reducing per capita healthcare costs.”

Policymakers could accelerate the value-based purchasing transition by implementing global capitation models with quality measurement, CAPP advised. The group described global capitation with quality measurement as “an ideal form of value-based reimbursement.”

However, CAPP acknowledged that many provider organizations are not prepared to assume the financial risk associated with global capitation payments. Therefore, policymakers should continue down the path to the ideal value-based purchasing arrangement by supporting and modifying existing Medicare and Medicaid alternative payment models.

Specifically, the industry group called for modifications to public accountable care organization (ACO) programs. Member organizations reported several challenges with participating in public ACO models, including patient attribution and data lags.

READ MORE: Best Practices for Value-Based Purchasing Implementation

“Under many models, we are not certain at the start of the performance measurement period which patients will be considered our responsibility,” the group explained. “If we do not know who our patients are in advance, we cannot proactively reach out to them for prevention and disease management.”

Attributed patients are also free to receive care from providers outside of the ACO, which makes it difficult for ACOs to effectively manage and coordinate care.

Furthermore, ACOs oftentimes do not receive timely performance and cost data. “With the shifting attribution of patients year to year, feedback may come too late, as groups of patients may be attributed to another provider by the time we receive information about their care,” they wrote.

The industry group advocated for public ACO models based on the Next Generation ACO program. The newest addition to the Medicare ACO family provides quicker data turnaround and patient attribution accuracy, member groups reported.

The Next Generation ACO model also contains greater downside financial risk than all other Medicare ACO programs. Policymakers should prioritize upping downside financial risk in public ACO models because the ultimate goal of value-based purchasing implementation is to make providers fully accountable for their care.

READ MORE: Understanding the Top 10 Terms of Value-Based Purchasing

To that end, CAPP advised policymakers to encourage CMS to address provider concerns with downside financial risk during this administration.

CAPP also called for bundled payment model changes. Policymakers should address the lack of coordination among public and private payers with the episodic care arrangement.

Payers across the spectrum have begun offering bundled payment models to move their providers to value-based purchasing. However, providers found when they took on bundled payments from multiple payers that care episode durations and scope of care differed by bundle. Some payers even offered multiple bundled payments that overlapped or conflicted with one another.

The lack of coordination creates administrative complexity for providers and CMS should act as a facilitator to push bundled payment model standardization for high-priority bundles, CAPP suggested.

“With such streamlining and simplification, we believe many more providers would choose to participate in bundles,” the group wrote. “We also believe that an inclusive stakeholder-driven process would lead to the use of broader outcomes measures in bundled-payment programs, including patient-focused outcomes, such as pain reduction and time required to return to normal activities of daily living.”

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

Additionally, policymakers can quicken the pace of value-based purchasing transition by supporting and expanding Medicare Advantage (MA).

Nearly one-third of Medicare beneficiaries belong to an MA plan. The popular Medicare arm reimburses plans through global capitation payments, making it a type of alternative payment model, CAPP argued.

MA plans also perform better than Medicare fee-for-service on several quality measures. For example, patients treated under a risk-based MA model had a 6 percent better survival rate than patients in a fee-for-service plan, a recent American Journal of Managed Care study showed. The MA group also experienced fewer emergency department visits and inpatient admissions.

With MA supporting value-based purchasing and improving patient outcomes, policymakers should ensure that the program grows alongside traditional Medicare.

“Most of the CAPP members have at least some capitated HMO [health maintenance organization] patients under MA, and we consider the program critical to our ability to innovate for greater value, efficiency, and convenience,” the group explained. “It is vital that if Medicare is expanded, MA expands with it; to expand only the FFS side of Medicare would be to encourage greater fragmentation and lack of coordination in the delivery system, undoing much of the progress made under value-based payments.”

Improving and expanding value-based purchasing models is key to accelerating the transition away from fee-for-service, CAPP reiterated.

“There is no single value-based payment program that works perfectly for all providers, all patient populations, and all types of care. Accordingly, payers and providers must continue to experiment with these systems and remain flexible to try new and different models,” they wrote.

The government should lead and encourage that experimentation as one of the largest purchasers and influencers in the industry.

“We ask policymakers to keep talking and listening to stakeholders who are exploring a variety of worthwhile ideas, such as expanding payment for telehealth and in-home care, implementing value-based insurance design, supporting dedicated care management for the highest-utilizers, and many more,” the group concluded. “Going forward, we ask CMS and Congress to remain open to partnering with providers, private payers, states and patients in new ways, providing more opportunities for the testing of innovative payment programs that enhance health care value.”