March 9, 2022
By Casey Korba, Director of Policy
CMS published the Advance Notice of Methodological Changes for CY 2023 for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies on February 2, and in addition to including the proposed payment policies, this year’s Advance Notice outlined clear intentions to continue paving a path for health equity and value in Medicare Advantage (MA) in the coming years.
Many of the proposed health equity elements and the proposal to develop a measure around value-based care in MA were in the Request for Information stages and will likely take years to come to fruition in future rulemaking. But the intent is clear, and Aledade applauds the agency’s commitment to health equity and value-based care across the health care system and in MA.
Our primary recommendations around the health equity proposals centered on supporting stratifying measures in Star ratings around social risk factors, and commending the agency’s goal to develop and implement a Health Equity Index to summarize measure-level performance by social risk factors into a single score. We also urged CMS to outline a clear strategy to be able to move from solely assessing MA plans’ beneficiaries’ social needs to measuring health outcomes, as screening and referral without meaningful follow up can be harmful to patients.
Aledade strongly supports defining value in MA
We are very pleased to see that CMS is interested in developing a value-based care measure to capture the arrangements MA organizations have with physician practices, including how plans are aligning incentives with practices so that they are rewarding better value over volume. Aledade fully supports efforts described in the Advance Notice to drive value among Medicare Advantage contracts and explore how MA organizations are transforming care and driving quality through value-based contracts. The US health care system is now more than a decade in on efforts to transform the system from volume to value, and it is clear that “value” has many different meanings and can be in the eye of the beholder. We would very much like to see CMS take this opportunity to define value in Medicare Advantage, as we collectively work toward the agency’s goal of having all Medicare beneficiaries in accountable relationships by 2030.
We support the development and implementation of a value measure that will let us know what percent of MA lives are in health care provider total cost of care accountability. We recommend CMS consider using the Health Care Payment Learning and Action Network’s (LAN) Alternative Payment Model Framework used to track progress on payment reform as a starting point for honing in that definition and development of a value-based care measure.
The framework lays out a scale of four categories on the way to value, with the first level being fee-for-service (FFS), with no link to quality or value. The second level describes FFS with a link to quality and value (in the form of pay for reporting and pay for performance). The third level moves toward Alternative Payment Models (APMs) built on FFS architecture (including APMs with shared savings and upside/downside risk), while the fourth level describes population-based payments that replace fee for service payments and reflect the total cost of care for treating a chronic condition, a limited set of specialty services, or comprehensive care for a population.
Using this framework, we would like to see a measure that identifies the number of primary care clinicians in each category and the number of MA plan members assigned to those clinicians. The measure simply being the number of contracted primary care clinicians (the Medicare Shared Savings Program definition can be used) as the denominator and then separate numerators for each category.
For simplicity, category 3 and category 4 could be combined. However, we believe it is very important to require category 2 be reported separately from category 3 & 4. CMS should clarify that to qualify for category 3 or 4 the MA plan must include cost as a component of the program and have a financial incentive directly related to the cost reduction. We make these clarifications to avoid the incentive to use the most lenient definitions of the categories as possible and we urge CMS to consider laying out definitive guardrails between the categories to negate that incentive.
We recommend that CMS include in the value measure a delineation of payer owned or payer parent owned provider entities. Independent primary care practices are the backbone of prevention and population health and we caution CMS to defend this measure against any disincentives to independent primary care practices. Research has shown that physician-led ACOs generate more savings than health system-led ACOs and deliver high quality care, and any new VBC measures should seek to avoid unfairly distinctive independent practices.
Medicare Advantage can play an essential role in helping providers make the shift to categories 3 & 4 so that more clinicians are rewarded for clinical and operational changes that lead to better outcomes and reduced costs to the system. Understanding the structure of different arrangements in MA is critical for continuing to develop strategies to strengthen alignment and performance. Developing and implementing a value-based measure in MA is a good step in the right direction to continue driving MA toward value.
Aledade looks forward to contributing to the further development of these proposals in future rulemaking
Health equity and value are inextricable at Aledade and are at the center of our mission. We support addressing these issues in the Medicare Advantage space, recognizing MA’s role as a catalyst for innovation. We advocate for overall alignment of health equity measures and goals in both traditional Medicare and Alternative Payment Models APMs coming out of the Center for Medicare and Medicaid Innovation (CMMI).
CMS will publish the final rate notice on April 4, 2022. We will continue to update you on the development of these initiatives and the ways in which Aledade is advocating for advancing health equity and value.