Three Value-Based Care Models That Continue the Shift Away from Fee-For-Service (FFS)

This article discusses two forthcoming initiatives set to launch in July 2024, aimed at moving away from fee-for-service payments in healthcare. Additionally, it introduces a third model, the AHEAD Model, which is designed to transform state and regional healthcare systems by aligning multiple payers and improving overall population health while reducing costs. Furthermore, the article underscores the importance of primary care as the cornerstone of a high-performing healthcare system.

The Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model

The AHEAD Model, a new voluntary “state total cost of care (TCOC),” is focused on driving healthcare transformation and multi-payer alignment at the state level. Its objective is to enhance the overall health of a state’s population and reduce healthcare expenses. Under the TCOC approach, participating states take responsibility for managing healthcare quality and costs across all payers, including Medicare, Medicaid, and private coverage. They also aim to ensure that healthcare providers within their state deliver high-quality care, improve population health, enhance care coordination, and promote health equity among underserved patients. The AHEAD Model provides participating states with funding and tools to address rising healthcare costs while advancing health equity.

Through the AHEAD Model, the Centers for Medicare and Medicaid Services (CMS) seeks to strengthen primary care, enhance care coordination, and increase screening and referrals to address social determinants of health. AHEAD is intended to provide additional resources to participating states to improve their population’s health, support primary care, and transform healthcare delivery within their communities. The ultimate goal of the AHEAD Model is to enhance healthcare outcomes and equity for all residents within participating states or regions.

The AHEAD Model builds upon the work of existing state-based models, such as the Vermont All-Payer Accountable Care Organization (VT ACO) Model, the Maryland Total Cost of Care Model (MD TCOC), and the Pennsylvania Rural Health Model (PARHM). What sets AHEAD apart is that CMS will implement it concurrently across multiple states, promoting a state-level, multi-sector approach to healthcare that advances health equity and coordinates resources to address underlying factors contributing to health disparities in underserved communities.

Guiding an Improved Dementia Experience (GUIDE) Model

On July 31, 2023, CMS introduced the GUIDE Model, a voluntary nationwide program scheduled to begin on July 1, 2024, and extend for eight years. The Model’s purpose is to address the deficiencies in dementia care by providing high-quality, coordinated care to individuals living with dementia. This initiative aims to reduce adverse outcomes, such as high hospitalization rates, emergency department visits, and post-acute care utilization, as well as depression, behavioral symptoms, and poor management of co-occurring conditions among those with dementia. Unpaid caregivers, often Medicare beneficiaries themselves, experience high levels of stress and depression which can negatively affect their health. The GUIDE Model introduces an alternative payment approach, providing services that include person-centered assessments, care plans, care coordination, and a 24/7 support line. Care navigators assist individuals with dementia and their caregivers in accessing services, including clinical and non-clinical support through community-based organizations. The Model also improves access to resources for caregivers, such as evidence-based education, respite services, and care management, enabling caregivers to continue providing support at home and potentially delaying the need for facility care.

The GUIDE Model offers two tracks for participation: one for established programs and another for new programs. Established programs must have an interdisciplinary care team and meet specific requirements, while new programs will have a pre-implementation period to establish their services. The Model addresses poor-quality dementia care by defining a standardized approach to dementia care delivery, providing an alternative payment methodology, addressing unpaid caregiver needs, offering respite services, and screening for health-related social needs. Furthermore, the GUIDE Model emphasizes health equity by targeting underserved communities, addressing disparities in dementia care, and supporting the development of dementia care programs in areas with limited access to specialized care. It also includes annual reporting on progress toward health equity objectives, using data to identify disparities and offering additional resources for underserved beneficiaries. In summary, the GUIDE Model is a significant CMS initiative aimed at improving dementia care, supporting unpaid caregivers, and promoting health equity in dementia care delivery. It encompasses a comprehensive set of services and strategies to enhance the quality of life for individuals living with dementia and their caregivers.

Making Care Primary (MCP) Model

The MCP Model introduces a new primary care alternative payment model and is set to launch on July 1, 2024. Piloted in eight states, it focuses on improving health equity for Medicare and Medicaid beneficiaries by involving small, independent primary care practices, even those with no prior value-based care experience. Over a 10.5-year period, participants will gain experience in care management services, behavioral health screening, and collaboration with specialists and social service providers. This innovative primary care model builds upon previous programs like Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models. Its primary goal is to enhance the delivery of advanced primary care services and strengthen the coordination of care between primary care clinicians, specialists, social service providers, and behavioral health clinicians.

MCP features three participation tracks designed to accommodate primary care organizations at various stages of value-based care adoption. It offers enhanced model payments, tools, and support to improve patients’ health outcomes, facilitate care coordination, and address patients’ health-related social needs (HRSNs) such as housing and nutrition. The model focuses on preventing chronic diseases, reducing emergency room visits, and achieving better health outcomes.

The three MCP tracks include Track 1 for building infrastructure, Track 2 for implementing advanced primary care, and Track 3 for optimizing care and partnerships. Eligible organizations must be Medicare-enrolled, bill for health services for a minimum of 125 attributed Medicare beneficiaries, and have the majority of their primary care sites in an MCP state. Rural Health Clinics, concierge practices, current PCF practices, and certain other organizations are not eligible for MCP.

Furthermore, MCP aims to improve health equity by addressing clinical indicators and social risk, requiring the development of strategic plans to reduce disparities, implementing HRSN screening and referrals, allowing cost-sharing reductions for patients in need, and measuring the percentage of patients screened for HRSNs. The model prioritizes equitable care for all Medicare and Medicaid beneficiaries.

In summary, the Making Care Primary (MCP) Model is a long-term primary care initiative that aims to enhance the delivery of advanced primary care services, improve care coordination, and promote health equity in eight participating states. It offers primary care organizations various tracks to gradually adopt value-based care and better meet the healthcare needs of patients.

Conclusion

Pinnacle recognizes the challenges faced by CMS in persuading physician practices to embrace alternative payment models, including excessive reporting requirements and inadequate participation options. It emphasizes the need to provide upfront resources, investments, and tools to help physician practices succeed in alternative payment models.

In conclusion, these CMS initiatives represent significant steps toward transitioning from fee-for-service payments to value-based payment structures in healthcare. They address pressing issues such as dementia care and aim to make it easier for smaller primary care practices to participate in alternative payment models, ultimately improving patient outcomes and managing costs.

CMS is also advancing a significant shift in healthcare delivery by introducing new models that extend beyond Medicare and encompass a multi-payer approach. The intention is to transform care coordination and management not only for Medicare beneficiaries but also to engage with state Medicaid agencies and eventually involve private payers. This multi-payer alignment is a crucial component of CMS’s strategy to promote comprehensive and high-quality primary care across diverse patient populations.

For more information on these new models or guidance on how to start in your value-based care journey, please contact Daniela Yusufbekova at 561-445-8303 or DYusufbekova@AskPHC.com.