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A graphic of multiple medical professional stylized vector drawings, the top left corner has text that states "Health Affairs Forefront, Accountable Care for Population Health".

Editor’s Note

This article is the latest in the Health Affairs Forefront series, Accountable Care for Population Health, featuring analysis and discussion of how to understand, design, support, and measure patient-centered, cost-efficient care under the umbrella of accountable care. Additional articles will be published throughout 2024. Readers are encouraged to review the Call for Submissions for this series. We are grateful to Arnold Ventures for their support of this work.

 

2024 marks the third year of progress on the Center for Medicare and Medicaid Innovation (Innovation Center) strategic refresh, and one of its aims is to have 100 percent of Traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships by 2030. Accountable care means that a doctor, group of health care providers, or hospitals take responsibility for improving quality of care, care coordination, and health outcomes for a defined group of patients based on a series of population-based metrics and cost based on a financial benchmark. Expanding accountable care will reduce care fragmentation and unnecessary costs for patients and the health system, but doing so also requires increased access to coordinated and integrated specialty care. When primary and specialty care providers collaborate across care settings, together they can deliver accountable care that best meets patients’ needs and preferences.

A comprehensive approach to accountable care must account for both primary care and specialty care. Specialty care is a critical part of the care experience and a substantial portion of overall Medicare spending. A 2021 research study shows that Medicare beneficiaries are seeing more specialists and seeing them more often than they were twenty years ago. A 2022 study suggests as many as 40 percent of Medicare beneficiaries receive care that is fragmented, with a mean of 13 visits across 7 clinicians in one year. Another study from 2018 links fragmented ambulatory care to higher rates of emergency department (ED) visits for Medicare beneficiaries with chronic conditions, finding that “beneficiaries with a moderate burden of chronic conditions appear to be at highest risk of excess ED visits and admissions due to fragmented care.”

To drive more person-centered care, specialists must be included on the path to paying for value. To tackle this challenge, the Innovation Center has laid out a comprehensive specialty strategy to test models and innovations that support access to high-quality, integrated specialty care across the patient journey. The Innovation Center has outlined pathways for specialty care coordination and integration to support person-centered specialty care in a previous CMS blog post. Here we provide an update on our progress towards implementing the different aspects of this strategy (see exhibit 1).

Exhibit 1. Innovation Center Specialty Strategy Goals

Source: Authors’ categorization of the Innovation Center’s new models and initiatives for each element of the Specialty Strategy.

Notes: ACO: Accountable Care Organization; BPCI-A: Bundled Payments for Care Improvement-Advanced; CJR: Comprehensive Care for Joint Replacement; EBPM: Episode-Based Payment Model; EOM: Enhancing Oncology Model; GUIDE: Guiding an Improved Dementia Experience; MCP: Making Care Primary; RFI: Request for Information.

Element 1: Enhance Specialty Care Performance Data Transparency

The first element of the Innovation Center’s specialty strategy aims to deliver enhanced specialty care data to clinicians, hospitals, and other health care entities across multiple models and programs. This requires a coordinated rollout of multiple data initiatives to support different kinds of providers and/or participants. The framework for data coordination and transparency is based on a survey of Accountable Care Organizations (ACOs) and advanced primary care model participants that asked what additional data would support specialty care engagement.

Beginning in February 2024, based on the feedback provided through the survey, the Innovation Center began providing “shadow bundles” data to ACOs in the Shared Savings Program and the ACO Realizing Equity, Access, and Community Health (REACH) Model. Shadow bundles are claims data for services, supplies, and their associated payments grouped into discrete procedural- and/or condition-specific episodes of care. Episodes are constructed based on a consistent set of rules for ACO-attributed beneficiaries who meet the criteria to trigger an episode. Benchmark prices are also provided to compare performance and facilitate sharing savings with providers. Shadow bundles data include summary data from raw claims that ACOs can use in their engagement with specialists. This CMS-generated standardized episode data gives ACOs insight into specialist care patterns, supporting their management of beneficiaries’ specialty care needs. Moreover, this standardized episode data supports ACOs that want to establish their own episode payment initiatives. Standard definitions for an episode of care allow ACOs to make comparisons on cost and quality and increase transparency and consistency across time to support high-value, accountable care.

Participants in the Making Care Primary (MCP) Model, which begins July 1, 2024, will receive performance profiles of specialty practices in their market. This will give MCP participants a comprehensive picture of the value of care being offered by specialty practices in their local service areas. MCP participants will receive specialty care metrics and beneficiary-level data through the model’s data feedback tool. This tool will include aspects of specialty care data never before shared with Innovation Center model participants, such as market-level metrics that may help MCP model participants identify high-performing specialists within their market. Specialist-attributed beneficiary data can provide MCP model participants more insight into the care delivered to beneficiaries by the specialists with whom they partner (termed “Specialty Care Partners”). In 2025, once Specialty Care Partners are identified, access to specialist performance profiles and shared MCP beneficiary-level data will be extended to them as well. As a next step, the Innovation Center is exploring ways to use this specialty care data to provide insights into how social risk factors (such as access to housing, food, and transportation) affect access to specialty care.

Identifying specialists providing the highest quality and lowest cost care for the treatment of common conditions or procedures will help primary care providers make more informed referral decisions, strengthening the efficiency and value of those referrals and supporting more integrated care.

Element 2: Maintain Momentum On Acute Episode Payment Models And Condition-Based Models

The Innovation Center has designed and implemented both acute episode models and standalone condition-specific models to target areas where beneficiaries experience gaps in high-value care. These models continue to be refined and serve as a foundation for the next generation of models. For instance, the Innovation Center released a Request for Applications for the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model in February of 2023 to extend participation in the model for two years to continue and increase provider engagement in episode-focused value-based care. On January 1 of this year, 207 participants with 247 episode initiators began participating in that two-year extension.

Last summer, the Innovation Center released a Request for Information (RFI) to gather feedback on a mandatory, episode-based payment model that would begin no earlier than 2026. Based on comments from the RFI and lessons learned from models like BPCI Advanced, the Innovation Center is considering a model that would incentivize coordination between acute care hospitals and other providers following an acute intervention such as a surgical procedure. CMS is also considering how such a model could include support for safety net providers and underserved beneficiaries, ultimately helping foster a complementary relationship between ACOs and hospital participants.

Condition-based models are also important for innovation in payment and care delivery. These models help focus on patients with specific health care needs by allowing a specialist to take on a more principal role in managing a patient’s care or by having a team of providers work together to provide a comprehensive set of services to address a certain health condition.

In the past year, the Innovation Center has made progress on several condition-based models that focus on specialty care providers who treat beneficiaries longitudinally in the community setting. This progress includes announcing the Guiding an Improved Dementia Experience (GUIDE) Model, which aims to support beneficiaries with dementia and their caregivers beginning July 1, 2024; launching the Enhancing Oncology Care Model (EOM) on July 1, 2023; and welcoming a new cohort of participants in the Kidney Care Choices (KCC) Model, which began in 2022. The EOM and KCC Models build on lessons learned from their predecessor models, the Oncology Care Model (OCM) and the Comprehensive End Stage Renal Disease (ESRD) Care (CEC) Model, respectively, to drive care transformation.

Element 3: Create Financial Incentives Within Primary Care For Specialist Engagement

The Innovation Center has explored ways to incentivize more primary care engagement with specialists. For instance, the MCP Model builds upon past Innovation Center models to make advanced primary care available and sustainable for a wider array of organizations that serve a broader and more diverse set of patients, thereby making a greater impact. The MCP Model promotes coordination between primary care organizations participating in the model and their Specialty Care Partners. This is done through new model-specific codes that expand the use of e-consults, which support ongoing communication among providers with a shared patient, and through the provision of targeted data through the MCP Model’s portal as described under Element 1. Moreover, the model is designed to foster primary and specialty engagement by helping participants become aware of and monitor for gaps in care or outcomes across the care continuum. For example, through participant collection of beneficiary-level demographic data and screening for social drivers of health, such as food insecurity and housing instability, participants may gain actionable insight into addressing longstanding inequities in our communities.

Whereas the above efforts seek to address specialty care integration within an advanced primary care model framework, the Innovation Center is also considering options to encourage specialty care provider engagement with primary care providers and beneficiaries in ACOs. The Innovation Center is exploring specialty-focused models that are mandatory and longitudinal in design to encourage specialist participation in value-based care, which would include a smooth transition to increasing risk for cost and quality over time, rather than requiring significant risk on day one. We also hope to capitalize on the existing structure of the Quality Payment Program’s (QPP) Merit-based Incentive Payment System (MIPS) Value Pathway (MVP) program, with a focus on geographic areas with high penetration of longitudinal, population-based models and programs that support opportunities for specialists to meaningfully engage with primary care clinicians who are seeking specialty care partnerships.

Element 4: Create Financial Incentives For Specialists To Affiliate With Population-Based Models And Move To Value-Based Care

To support ACOs in their delivery of high-quality care and achievement of cost savings, the Innovation Center is considering ways to create incentives for specialists to affiliate with ACOs. A key goal of this work is ensuring that ACOs can meet the specialty care needs of their beneficiary population, particularly those beneficiaries who have historically experienced challenges accessing specialty care, and that beneficiaries experience longitudinal, accountable, and coordinated care. The Innovation Center is exploring several options that could be embedded in future population-based models, including developing subpopulation targets that facilitate new payment approaches for high-volume or high-cost conditions and exploring how the provision of data to ACOs can bring specialists into value-based arrangements.

Addressing Gaps In The Beneficiary’s Journey

Fragmented, uncoordinated, and transactional care does not always equitably meet the needs of many beneficiaries and communities. Addressing the entirety of the beneficiary’s journey requires purposeful incentives to reach providers at each step of the way: by delivering data for more transparency in specialist performance; by refocusing longitudinal specialty care on the beneficiary experience and outcomes; and by facilitating specialty care partnerships with primary care-based ACOs that are steadily moving towards full accountability (see exhibit 2).

Exhibit 2. The care continuum experienced by beneficiaries from chronic disease onset to end-of-life care

Source: Japinga M, Jayakumar P, De Brantes F, Bozic K, Saunders R, McClellan M. Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms [White Paper]. Washington, DC: Duke-Margolis Center for Health Policy. 2022.

The Innovation Center remains committed to supporting both primary and specialty care practices in delivering coordinated and state-of-the-art care so that patients feel empowered to make decisions about their treatment and overall approach to managing their health.

In 2024 and beyond, the Innovation Center will continue to advance its specialty strategy through a carefully crafted portfolio of models and initiatives so that the 2030 goal of accountable care for Medicare and Medicaid beneficiaries remains firmly on target.

Authors’ Note

All authors are employed by the Centers for Medicare and Medicaid Services.

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