Pulse Check: Value-based Care Models and the New Administration

From within the new leadership at Health & Human Services (HHS), some anticipated and current payment models tied to MACRA are advancing, while others not-yet-tied to MACRA are being delayed.

MSSP Track 1+ was officially unveiled post-election through a CMS webinar March 22, and CPC+ has moved to round two. Also, but prior to the presidential election, CMS put forth several new bundled payment models whose start dates have been delayed.

Track 1+

The CMS ACO Track 1+ is being designated as an advanced-alternative payment model (A-APM) for MACRA, meaning qualified participants would be eligible for the up-front five percent MACRA bonus, and would be exempt from MIPS scoring.

Track 1 will remain with its MIPS APM designation.

The difference is Track 1+ comes with downside risk, though less than that of Track 2 or Track 3 models, themselves also A-APMs.

Billed as a bridge or migration up (or down) the risk ladder, one highlight is that participants currently in the Track 1 timeline can shift to Track 1+ for the duration of current agreements if desired. Overall, new, renewing or current applicants/participants can consider Track 1+.

Like with all federal models, there is a lot of fine print, which can be found here in a CMS fact sheet, which includes a crosswalk of all four models. Some other highlights:

— Jan. 1, 2018 start date available, as a three-year agreement
— May 1 notice to apply
— July 1 to submit applications
— 2019 and 2020 start dates also available
— Participants of Track 2, Track 3, Pioneer or Next Generation models cannot participate, nor can those whose legal entity is a health plan

Quality measures align with other tracks, as does the minimum of 5,000 beneficiaries

The model uses a prospective beneficiary assignment, and shares Track 1’s basics such as a 50 percent maximum shared savings rate, and two risk arrangements are offered (revenue- or benchmark-based loss sharing limit)

So what’s different? The loss sharing limit of four percent – see fact sheet details –  and some embedded benefits found in Track 3 such as the SNF waiver.

Comprehensive Primary Care Plus

CPC+, currently in its first performance year also as a MACRA A-APM, should reopen for practice applications this coming summer.

Right now, new payers and payer regions are being solicited by CMS with an early April deadline, which of course could extend. But the goal is for up to 10 new regions to become available, expanding from the 14 regions now underway.

Practices located in the 14 original regions will not be able to apply, CMS has announced.

Participants in CMS ACOs, including the new Track +1 model, can still participate simultaneously in both models overall.

CPC+ is a multi-payer program focusing on care management and quality reporting that has been pretty-well received so far. It also offers a Track 1 or Track 2 pathway offering increased value-based care incentives in Track 2, but also more advanced health IT capabilities.

Bundled Models Delayed

On December 20, CMS announced several specific models as part of the agency’s overall quest to move Medicare payments away from fee-for-service to quality. These specialty-heavy bundled payment models included:

— Acute Myocardial Infarction
— Coronary Artery Bypass Graft
— Cardiac Rehabilitation

But, on March 20, new HHS leadership announced it was delaying the start date of these models from July 1 to October 1, done through a notice in the federal register.

The models were not specifically tied to MACRA when announced, and may or may not find their way into the program for the 2018 performance year. The announcement to delay noted the new administration wanted time to study the models and institute a comment period.

Prior to all of this, on December 15, CMS under the old regime did announce new models and updates tied to the 2018 MACRA performance year, including:

Track 1+,  a “new voluntary bundled payment model,”
Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track), and expansion of the Comprehensive Care for Joint Replacement Payment Model (CEHRT track) that was launched in April of 2016, and currently applies to 800 hospitals.

But here again, in the same federal register notice, HHS announced it is delaying the expansion of the Joint Replacement model from July 1 to October 1 of this year. The expansion aspect seeks to add another retrospective bundled payment in existing regions under a new Surgical Hip and Femur Fracture Treatment model.

MACRA factor?

This overall move by HHS on March 20 has of course led to speculation about the agency’s motives. New HHS Secretary Tom Price is on the record as being against mandatory bundled payment programs, so there is speculation as to whether the delay is a death-knell or not. Price favors voluntary bundled payment models and what he calls physician-friendly models, so it would not be surprising to see such structural changes, though to many that could be reminiscent of ONC’s voluntary certification program no one signed up for. Changing the models to voluntary, but placing them within MACRA’s A-APM track and its benefits around bonus funds and exemption from MIPS, could help draw participants within a voluntary structure.

So, for these models, we’ll have to see, and it’s no coincidence that the term “CEHRT” is being noted in some model titles. For vendors, 2017 is an important year for another reason, as the 2015 Edition of ONC health IT product certification carries with it a deadline of Jan. 1, 2018.

It’s also noteworthy that MACRA itself has language written into the law for the construction of brand new payment models – and many have already been externally proposed – which would ultimately be put forth by Price and new CMS Administrator Seema Verma, who was just sworn in on March 13.

And finally, amid speculation that the so-far failed effort to repeal and replace the healthcare insurance side of the Affordable Care Act (ACA) would also mean the end of ACA’s policy side that created VBC models such as ACOs and led to the formation of the Center for Medicare & Medicaid Innovation (CMMI) – which creates these models – Price’s HHS did announce on March 13 provisions for state innovation waivers that cite and leverage ACA. This sends a broader signal that that side of ACA is not part of any future repeal and replace around the health insurance market.

Greg Fulton is industry and public policy lead at Philips Wellcentive.

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1 reply »

  1. Now retired almost 6 months as a Primary Physician, reading this level of obfuscation still gives me a mental panic attack. To even think about this as part of a daily health care commitment ………..
    I understand that the First Amendment gives me a right to petition. Does any one know how many signatures would be required? In 2014, there were 916,000 licensed physicians in the USA, So, it would take at least 500,000 verifiable M.D./D.O signatures to cancel MACRA based on a class action concept. Hmmmmm, I wonder. Probably, winning the lottery has better odds, and I don’t play the lottery.