The Task Force Sends CMS Recommendations for Aligning the Alternative Payment Model Portfolio

The Health Care Transformation Task Force sent a comment letter to CMS with recommendations for improving alignment between primary care and specialty focused models. The letter highlights current model design elements and APM overlap policies that indirectly hinder and directly disincentivize cross-model alignment, defines key elements of model design that need to be addressed to promote alignment, and recommends a methodology for managing model overlaps in the future.  

Task Force Comment Summary 

Task Force recommendations for advancing APM alignment efforts cover four main areas: barriers to APM alignment, design elements for future APMs, cross model alignment strategies, and approaches for promoting equity. 

  1. Addressing Barriers: HCTTF encouraged CMS to act on the structural barriers in the current APM landscape that interfere with alignment efforts. Key barriers included: 

    • Addressing unnecessary complexity caused by overlapping model timelines by aligning new model launch schedules and application requirements so participants can compare APM opportunities side-by-side. 
    • Allowing model participants greater flexibility to create high quality provider networks by extending the TIN-NPI participant selection approach to MSSP and future APMs. 
    • Creating aligned incentives for quality improvement across model types by collaborating with stakeholders and using existing measure sets to develop outcome-oriented measure sets that can apply to primary care and specialist models. The quality measurement strategy should balance efforts to minimize provider reporting burden with the goal of selecting clinically meaningful and actionable measures. 
  2. Future Model Design Elements: Task Force members identified several aspects of model design that CMS should address to enable cross-model alignment and made recommendations for the role of CMMI in the development of future bundled payment and episodic models. The recommendations included: 

    • Designing benchmarking methodologies that align across models and establish clear incentives for population-based model participants and bundled payment providers to partner. In the event that this alignment cannot be achieved, CMS should limit the potential for the benchmarks it set in one model to harm the financial performance of participants in another model.  
    • Gaining broad and sustainable model adoption among a critical mass of providers with the goal of improving quality while achieving predictable and sustainable health care cost growth. To accomplish this CMS should provider on-ramps for providers new to APMs, create benchmarking options that address the ratcheting effect to reward and retain efficient providers, and explore options for alternative benchmarking approaches that do not rely on current FFS spending to promote long term sustainability. 
    • Playing an active role in the design and operation of models targeting specific service lines and conditions. These efforts should focus on two areas: 1) procedural episodes where a beneficiary has a time limited relationship with a provider to address a specific issue, and 2) Chronic Condition-Specific Models built around a limited set of chronic health conditions where specialists play a predominant role in managing care longitudinally or for discrete periods of time as the condition is in an acute phase. 
  3. Strategies for Cross-Model Alignment: HCTTF recommended that CMS pursue a hierarchical model alignment strategy. This strategy should set a clear, consistent, and predictable beneficiary attribution policy supported by financial arrangements that: 1) allows providers delivering complimentary care to mutually benefit under their respective models, and 2) strives to minimize cross-model gaming opportunities that drive adverse incentives such as participant selection bias or freeriding. To do this we recommended that CMS: 

    • Allow high-risk ACOs the flexibility to either: 
      • Participate in bundled payment models designed and operated by CMS. Under this option the ACO would identify a set of bundled payment arrangements and a list of participating specialists for CMS to apply the bundled payment arrangement to. The ACO would retain beneficiary attribution, CMS would make direct payments to providers under the bundled payment model, and all bundled payment spending would be reconciled against the ACO TCOC benchmark. 
      • Opt-out of CMS designed bundles. Under this option ACO aligned beneficiaries would not be eligible for any other payment models. Instead, ACOs may choose to contract directly with specialists, receive funds from CMS, and manage downstream payments. ACOs would have the latitude to design these contracts and would retain responsibility for TCOC. ACOs would also have the discretion to not enter into any downstream contracts. 
    • Establish model alignment policies for low and moderate risk ACOs that preferences models based on the nature of the clinical condition covered by the model and the degree of responsibility the provider is accepting for beneficiary care coordination, cost, and quality. Under this policy, beneficiary attribution would work as follows: 
      • When a beneficiary with a chronic condition receives care under both a low or moderate risk ACO and a relevant chronic-condition model, alignment preference would go to the chronic condition model provider when the specialist serves as the central coordinating point of care for beneficiaries (such as ESRD) and is willing to accept greater risk for the total cost of care and quality.  
      • When a beneficiary is receiving care from a low or moderate risk ACO model and receiving treatment from a provider participating in an procedural episode, beneficiary alignment would remain with the ACO model. 
      • When a beneficiary is not receiving care from any ACO provider but is receiving care from a provider in another APM, then attribution would default to the other APM (with chronic-condition models taking precedence over procedural episodes). 
    • Leverage model participation requirements to promote alignment by requiring applicants to chronic-condition models and procedural episodes to have explicit contractual relationships, defined referral pathways, and clear coordination plans with primary care providers in population-based APMs. 
  4. Advancing Equity: HCTTF expressed support for the emphasis on health equity that CMS has placed at the core of new payment model design efforts. We urged CMMI to continue leveraging a multi-faceted approach to incorporating equity considerations into models. This should include:

    • Participant requirements for formal health equity plans
    • Benchmarking and risk adjustment strategies that account for beneficiary and community level equity and are designed for providers working in underserved communities
    • Demographic data collection standards and quality measurement strategies that encourage the closing of health equity gaps

Read the Letter