CMS takes on quality with new value-based care initiatives

 The Center for Medicare and Medicaid Services Innovation (CMMI) is hard at work expanding the influence of value-based care (VBC) across the healthcare industry. With a pair of recently introduced initiatives, including a revamped guiding philosophy and a new accountable care organization (ACO) option, CMMI is hoping to make it easier and more rewarding for healthcare providers to participate in innovative financial models. 

After more than a decade of value-based care development, these changes are intended to “rebalance” the historical emphasis on reducing spending with a greater focus on quality and outcomes and create more opportunities for smaller, low-revenue primary care providers to see success in the VBC environment.    

A renewed commitment to quality and patient experiences 

In an article published in the New England Journal of Medicine, CMMI introduced its new Quality Pathway: an effort to ensure that VBC models pay closer attention to fostering better outcomes, not just cutting costs.   

While it’s not a new model in and of itself, the Quality Pathway will guide the optimization of existing models and inform the design of future VBC models by aligning quality goals, advancing the use of person-centered measures of outcomes and experiences, and designing evaluations to better assess how models assist with achieving patient-centered quality goals.   

During this process, patient-reported measures will become more important for evaluating care quality, CMMI said. 

“The Quality Pathway will at times lead to the development, testing, and introduction of new measures to address gaps in validated measures addressing a model’s quality goals,” wrote the team. “We recognize that new measures, especially those that are patient reported, can be challenging for model participants who need time to incorporate them into clinical workflows…[so] we may incrementally introduce new measures before tying performance to payment.” 

In addition to patient-reported data, future models may also incorporate randomized, controlled data, similar to clinical trials, to gauge the effectiveness of interventions at scale. CMMI is still considering how this type of evaluation might occur. 

“We recognize the challenges in implementing the Quality Pathway, including the clinician workload associated with additional quality measure reporting, but we believe that the benefits gained from the integration of the Quality Pathway will help drive broader care improvement for patients, and therefore merit these efforts,” the article concluded. 

“The Quality Pathway will ensure that each model is designed with a defined focus to drive better patient outcomes and reduced health care costs for taxpayers and patients. It will also ensure that each model includes aligned tools and payment mechanisms to drive that improvement and uses evaluation methods to best determine the impact of the model on quality of care.”  

ACO Primary Care Flex aims to expand the value-based care community  

In alignment with this quality-driven mission, CMS has announced the availability of the new ACO Primary Care Flex model, which sits under the Medicare Shared Savings Program (MSSP) umbrella. 

This new accountable care organization pathway is intended to bring more low-revenue ACOs into the ecosystem. These groups, typically led by primary care physicians and/or small and rural hospitals, have been shown to achieve more savings and demonstrate stronger performance around quality and efficiency.  

According to the announcement, the overarching goals of the model include:  

• Expanding access to high-quality accountable care and improve patient experiences for Medicare beneficiaries 
• Providing additional financial support for the primary care community while implementing innovative approaches to proactive, person-centered care delivery 
• Narrowing disparities in healthcare outcomes and improving health equity 
• Reducing program expenditures while maintaining high quality of care

To strengthen financial incentives for participation, the model will include a Prospective Primary Care Payment (PPCP) option to offer more predictability and flexibility for ACOs with limited resources, as well as a one-time Advanced Shared Savings Payment to offset the expenses of forming and ACO and starting up model-related activities. 

“The design of the PPCP as a flexible, predictable revenue stream that can exceed existing payment levels is expected to appeal to many low revenue ACOs,” CMS said. “The flexible payment design will empower participating ACOs and their primary care providers to use more innovative, team-based, person-centered and proactive approaches to care.” 

The model begins on January 1, 2025, and will run on a voluntary basis for 5 years. CMS is planning to enroll approximately 130 ACOs, all of which must first apply or renew their status within the MSSP before applying for ACO PC Flex. 

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.