During a fireside chat at this week’s Health Care Learning and Action Network Summit Meeting, Sarah Fogler, Ph.D., MA, of the Center for Medicare & Medicaid Innovation, spoke about the decade of CMMI’s experience in creating alternative payment models for specialty care, and also spoke about upcoming opportunities in this space.
Fogler is acting director of the Patient Care Models Group, which develops and implements episode-based payment initiatives, including the Bundled Payments for Care initiative – Advanced Model, Comprehensive Care for Joint Replacement Model, Oncology Care Model, Enhancing Oncology Model, Home Independence and Intravenous Immunoglobulin Demonstration. Prior to joining the CMS Innovation Center, she served as Senior Director of Population Health and Community Benefits at Greater Baltimore Medical Center in Baltimore.
She was interviewed by Amol Navathe, MD, Ph.D., a tenured faculty member in health policy and medicine and a senior researcher at the Leonard Davis Institute for Health Economics at the University of Pennsylvania. He is Vice Chairman and Commissioner of the Medicare Payment Advisory Commission (MedPAC), a nonpartisan agency that advises the US Congress on Medicare policy.
Fogler noted that the CMS Innovation Center has established a comprehensive strategy to integrate specialists into value-based payment programs aligned with the CMS Innovation Center strategy update.
“Over the past decade, we have built and continue to refine a solid foundation of accountability across a number of key specialties and conditions. We did this alongside but separately from our model tests of advanced primary care and accountable care organizations,” she said. “While the strategic refresh focuses on improving specialty care, we expect these accountability structures to coordinate with or more fully integrate specialty care to provide comprehensive care for Medicare and Medicaid beneficiaries.”
To date, she explained, specialist care models have focused on inpatient medical and surgical admissions and procedures in hospital outpatient departments. There are episode-based payment models, including bundled payments for care improvement initiative models and a comprehensive care model for joint replacement. “These models have driven transformational changes in the delivery of care across transitions, including between post-acute care hospitals and community supports,” she said.
Fogler added that in addition to episode-based payment models, the CMMI has made gains through specialized models that focus on conditions – particularly for oncology and kidney disease, including the model of Oncology Care and the New Enhanced Oncology Care Model and Renal Care Choices and the Comprehensive Model ESRD Program. “There remain opportunities for fragmentation between primary care providers and specialists, improving access to high quality specialist services and involving more specialists in value-based payment in general. So that’s where we’re focusing on the key areas of our specialty strategy moving forward.
Navathe asked Fogler to go into detail about the primary care/specialist interface because, he said, “many of us who work in space, who study that space, who try to ‘to be innovators, have a hard time with it’.
“We have four explicit and discrete areas of focus in our specialty care strategy, and this extends in a very focused way across the continuum of care for recipients,” Fogler responded. “The first area of focus of the specialty strategy relates to data sharing to improve transparency. and clinician performance. This isn’t a new area for the agency, of course, but we’re focused on doing a better job of arming our data provider partners to make informed decisions about who they want to engage with. as specialist care partners.
She said the second area of focus is to continue CMMI’s history of testing large-scale episode-based payment models that deliberately align with ACOs and primary care, and that would include mandatory models in the future.
The third component of the specialty care strategy is to help specialists become more integrated into primary care-oriented models. “We haven’t explicitly tested a primary care model, although we’ve done a ton of work in the primary care space, really layering this specialist care partnership within the base of the primary care model that we tested at the innovation center,” she says, “so we’re excited to do even more work there.”
The fourth element of the specialty care strategy is to create incentives within population-based models to encourage the integration of specialty care. That doesn’t necessarily mean new models, Fogler said. “It could be tools and different programmatic waivers or other similar things that we could introduce into our population-based portfolio that could encourage the integration of specialist care.”
Navathe asked Fogler for more details on creating incentives for integrating specialists into models primarily designed for primary care or populations. “I could imagine this, for example, as co-located endocrinology for diabetic patients. Are these incentives for this kind of structural change in the delivery model? Or is it more around results? Try to explore this interface between PCP and specialists?
“I will say that the fourth part of the strategy is the one that we have identified as longer term,” Fogler replied. Lessons learned in the short term will inform this fourth installment, she said, adding that they were considering a few different levers. One involves modifying beneficiary alignment algorithms to go beyond traditional E/M outpatient services and to include more inpatient services. “For example, we are also considering developing subpopulation targets for high volume or high cost conditions that can be reintroduced through the formality of model design or through the informality of arming tools and supports, e.g. example, ACOs with additional information about what their terms cost within their network and for their assigned beneficiaries,” she said.
Fogler noted that the CMMI realizes that the calculations of an ACO are different for integrated delivery systems and hospital-led ACOs versus physician-led ACOs. “That has been a distinguishing feature of this fourth component of the specialty strategy which is to think hard about how the levers need to be different for hospital-led versus physician-led ACOs,” a- she declared. “A key piece of this puzzle that we’ve started to unpack is that hospitals can’t always justify a decrease in referral volume if an ACO shared savings rate doesn’t sufficiently cover lost revenue, so it makes sense that ACO savings to date have been concentrated among physician-led ACOs.
Meanwhile, she added, the fastest vertical integration has occurred among specialty practices compared to primary care, namely in oncology and cardiology, meaning that these specialty practices increasingly belong in addition to hospitals and are less likely to join PCP ACOs. “We know we need tailored approaches and incentives for these different types of model participants with different economic and market-based incentive structures,” Fogler said. “Our plan is to work over the next few years as we develop strategies to support the first three elements of the specialty strategy to really inform the future design of this population-based integrated fourth specialty strategy.”
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