The Centers for Medicare and Medicaid Services (CMS) is charging forward with its plan to bring Medicare and Medicaid beneficiaries into coordinated care models.
In 2021, the Centers for Medicare and Medicaid Services' Innovation Center (CMMI) released its strategic refresh to have all Medicare beneficiaries and the majority of Medicaid beneficiaries enrolled in accountable care relationships by 2030. Under these relationships, CMS aims for beneficiaries to experience longitudinal, accountable care with providers that are responsible for the quality and total cost of their care.
The strategy is based on previous models CMS has implemented, including the Bundled Payments for Care Improvement (BPCI) Model, the BPCI Advanced Model, which was recently expanded for another two years, and the Comprehensive Care for Joint Replacement (CJR) Model, plus condition-based episode payment models, such as those focused on oncology and kidney disease.
Currently, Medicare beneficiaries often experience fragmented care that is costly, with multiple specialists across sites of care. Over the past several years, more patients are being seen in outpatient settings, and Medicare beneficiaries saw an average of 50 percent more specialists in the outpatient setting in 2019 compared to 2000. That means primary care providers are dealing with double the number of physicians to coordinate care. Among Medicare-fee-for-service beneficiaries, 4 in 10 experience highly fragmented care, according to one 2022 study cited by CMS.
On the Medicaid side, beneficiaries often experience barriers to accessing care, such as challenges scheduling specialty visits. This is primarily due to low specialist payment rates, low in-network specialist coverage, administrative burden and lack of Medicaid coverage for telemedicine. Patients also often report long travel and distances, as well as out-of-pocket costs as barriers to care.
According to CMS, the consolidation across the healthcare space has also impacted access to specialty care and value-based care.
“The most rapid vertical integration has occurred among specialty practices, namely oncology and cardiology, and this increasing shift to hospital employment may increase the costs of care without improving quality,” CMS said in a blog post about the first-year findings. “Market consolidation may dampen value-based incentives, in part because hospital-employed physicians are often paid by volume of procedures, which rewards referral volume.”
The strategic refresh will continue testing new payment models and releasing new accountable care models to reduce costs and improve quality, as well as support greater coordination and integration across primary and specialty care. The agency also wants to give model participants the ability to compare the quality and costs of procedural or acute episodes of care.
Moving forward, CMMI is focused in four areas to meet its goals:
- Enhance transparency in clinician performance
- Continue deployment of episode payment models that align with ACOs and primary care including mandatory models
- Support specialists to further embed in primary-care focused models
- Create incentives within population-based models to encourage specialty care integration
“While we work on improvements to value-based payment models and to restructure payment, our goal remains ensuring every beneficiary gets the best possible care, while advancing equity, promoting affordability, and expanding access to whole-person care,” CMS stated.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."