CMMI Expanding Direct Contracting, Advancing Other New Models

A top official at the Centers for Medicare & Medicaid Services (CMS) sought to reassure accountable care organizations (ACOs) that the agency has been and will continue to be “flexible” and “thoughtful” in addressing ACOs’ concerns in the midst of the COVID-19 pandemic, while also stressing the need for providers to take more risk.

“When things happen [that] none of us could have predicted, we’re going to be flexible. We’re going to be reasonable. We’re going to respond in a thoughtful way,” said Brad Smith, deputy administrator and director of the Center for Medicare & Medicaid Innovation (CMMI) at CMS and the former CEO and co-founder of Aspire Health, speaking at a virtual panel hosted by the National Association of ACOs (NAACOS) during its Fall 2020 Conference on Tuesday.

As one example, CMMI has opened up a second cohort in its Direct Contracting models that will begin in 2022, recognizing that some practices may have missed the chance to enroll this summer due to pandemic-related disruptions. The application period for the 2022 cohort will be due next spring.

The Direct Contracting model is part of the Primary Cares initiative announced in April 2019. The model allows practices to be paid more when patients stay healthy, but requires practices to take on risk if patients end up sicker; this track is meant for larger practices that have some experience bearing financial risk.

NAACOS sent a letter to CMS Administrator Seema Verma on Wednesday, acknowledging that the agency has already granted its members certain accommodations because of the pandemic, but also urging CMS not to move forward with changes to quality measures for ACOs and alternative payment models in certain programs.

“Just as CMS has proposed to delay moving forward with the MIPS Value Pathways approach due to concerns with COVID-19, CMS should also postpone such a drastic and significant change to the way ACO quality is measured, assessed, reported and scored for purposes of both the [Medicare Shared Savings Programs] and [the Merit-Based Incentive Payment Systems],” said NAACOS in a press release.

Changes suggested in the 2021 Medicare Physician Fee Schedule would alter what and how ACOs report, and have been introduced during a period of “uncertainty,” stated NAACOS. In addition to reducing spending, ACOs receive shared savings payments based on their ability to meet certain quality performance standards.

CMS has suggested the following changes:

  • Ending the use of a Web Interface, that practices have leveraged since the start of the MSSP program.
  • Changing certain quality measures that ACOs report under a new Alternative Payment Model [APM] Performance Pathway
  • Replacing the current “MIPS APM Scoring Standard,” which tailors the quality measures to fit a particular model
  • Removing the pay-for-reporting year currently given to those ACOs just starting an MSSP contract and certain newly introduced measures

The letter also pointed out that the final rule’s delayed release shortens the time ACOs and other entities would have to enact the changes.

Several other medical groups including the American Medical Association, the American College of Physicians, and the Federation of American Hospital signed on to the letter.

During the conference Tuesday, Smith also spoke more broadly about the lessons of the pandemic for ACOs.

Prior to the COVID-19 pandemic, many people thought of value-based payment models as “something that was kind of on the side, but I think with some of the changes and the pressures that people have felt over the past months … that this move to value is only going to go faster,” he said.

As Verma pointed out in a recent Health Affairs blog post, “The trauma of the pandemic has underscored the need for a resilient health care system where reimbursement is not tied to volume of services provided, but rather to value-based incentives to keep patients healthy.”

Smith said, “At some point it becomes really important that we hit a tipping point … and it will hopefully move large numbers of beneficiaries into value-based care.”

“I think when you think about the next 5 or 10 years of CMMI, if we’re successful we’ll move value-based care from something that might be 10, 20 percent of somebody’s revenue to something that’s 80 or hopefully 100 percent of somebody’s revenue,” he said.

That will require having successful models that can be scaled, and that “push big pieces of risk and payment into value … at a pace that people can be prepared for … that’s where you’re going to see us focus,” Smith said.

To that end, the agency plans to “continue moving forward with all of the other models that we’ve announced,” including the Radiation Oncology Models that the agency announced last week and the direct contracting in Kidney Care Models, which will go into effect in April 2021, Smith said.

Also, he noted, at the request of CMS Administrator Seema Verma, CMMI reviewed 54 existing payment models to see what worked and didn’t.

Smith and his colleagues found “a number of models that have had meaningful financial success” including both the Community Health Access and Rural Transformation (CHART) Model, which aims to help rural communities join the value movement and the ACO Investment Model (AIM), which is intended to assess the use of pre-paid shared savings to practices.

As background, CHART has two key tracks: One provides “startup funding” for an ACO to participate in the Medicare Shared Saving Program; and the other, the “Community Transformation Track,” provides grants and waivers that will help health systems improve their control of population health. CMMI will begin taking applications for the start-up track next spring, and applications for the second track are due in early 2021, with the program slated to start in mid-2021.

Other models had seen strong improvements in quality, including the Kidney Care Models, which reduced the number of hospitalizations and emergency starts on dialysis, Smith said.

Looking back at certain models, including bundled models and oncology models, the savings the program experienced were not the types of savings the center expected, he said. But because of its analysis, CMMI was able to glean lessons about improving benchmarking, which Smith said will allow the center to make adjustments and more accurately predict future costs.

“If we’re able to truly generate savings, I believe we’ll be able to accurately measure that, which will allow us to extend a model like direct contracting long-term,” Smith said.

He also highlighted a few of the models “coming down the pike.”

One model is focused on improving care coordination for dual eligibles — participants in both Medicare and Medicaid — and another is a model focused on direct contracting in a certain geographic area.

In this second model, participating providers could take on risk for all Medicare beneficiaries or a portion of Medicare beneficiaries in a certain geographic region.

Both of these models are in development, and Smith said he hopes to have more news to share about them later in the year.

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    Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow

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