Assessing value-based care will require streamlining Medicare regulations across its different programs, defining value and measuring for it, according to the American Medical Group Association (AMGA).

The recommendations came in response to a request for information from the Assistant Secretary for Planning and Evaluation (ASPE) at HHS on how to “promote choice and competition and reduce regulatory burden” throughout healthcare markets. AMGA president and CEO Jerry Penso, MD, MBA said much of the problem stems from Medicare’s lack of unity, with vastly different regulatory requirements for its three separate payment systems: Medicare fee-for-service (FFS), Medicare Advantage (MA) and the accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP).

The result, Penso wrote, has been a demanding annual rulemaking process requiring too much time for providers to follow, all while taxpayer money funds “what amounts to an underperforming and spending inefficient Medicare program.”

“Fielding three Medicare programs might make sense if they were designed to compete against one another. They do not. They exist in silos,” he wrote.

Breaking down those silos will require a radical change in Medicare, aligning how those three systems are financially bench marked, risk adjusted and reward providers for quality performance. Penso pointed to simulations conducted by the Medicare Payment Advisory Commission in 2014, 2015 and 2016 which found none of the existing models was the lowest cost option in all 78 markets it studied, meaning up to one-third Medicare beneficiaries are paying more for a less cost-efficient program.

This shift to “neutral payments” would be disruptive, but would also “expose inefficiencies and drive market share away from the less efficient,” Penso wrote while extending Medicare’s financial solvency and promoting competition by “leveling the playing field” between the three systems.

“Among other reasons, participating Medicare providers would want to know which program in which market is the most spending efficient. With MA and ACO quality performance measured against FFS, providers in FFS…would be able to use quality performance to compete for market share,” he wrote.

When it comes to achieving the goals of value-based care, Penso wrote Medicare, like the rest of the industry, isn’t measure for results. He cited several examples: a lack of correlation between quality performance and earned shared savings in MSSP, rewarding low-spending, low-quality hospitals in the Hospital Value-Based Purchasing program and scoring quality and cost separately in the Merit-based Incentive Payment System (MIPS).

The “Meaningful Measures” initiative announced by CMS to focus on outcomes-based measures, rather than process compliance, is an acknowledgment of the problem. Penso encouraged the agency to work with the International Consortium for Health Outcomes Measurement (ICHOM) and their 22 existing sets of outcomes measures—and particularly focus on patient-reported outcome measures.

AMGA has been critical of recent CMS moves on value-based care, opposing the exemption of more clinicians from MIPS while agreeing with MedPAC that MIPS should be repealed. More aggressive regulatory movement on “driving to value” and breaking down silos could make Medicare “more than sum of its parts.”

“We are confident that taking regulatory steps in these directions would encourage and enable ‘the development and operation of a healthcare system that provides high-quality care at affordable prices,’” Penso concluded.