Shaping value-based care transformation

Advocating for Physician Fee Schedule improvement in benchmark calculations for Medicare Shared Savings Program ACOs, including areas around risk score caps, the rural glitch, and quality measurement.

The “rural glitch” penalizes certain ACOs in rural areas and other health professional shortage areas, when they are successful at delivering better care at lower costs. This happens because an ACO’s beneficiary population is included in the regional trend calculation, so they are penalized for making improvements to patient care and achieving savings when CMS determines their benchmark the following year. When an ACO reduces costs, this carries over to also reducing the region's costs; this effect increases the more beneficiaries an ACO has in its region. Unfortunately, many of these ACOs are disproportionately located in areas where there is a shortage of health professionals, such as rural areas and underserved communities, where CMS has stated it wants to see more participation in value-based models.

At Aledade, we believe there is still opportunity for significant growth in ACOs. In the fall of 2021, we outlined in Health Affairs the case for using the MSSP as a “chassis” for innovation. In 2022, we followed up with a series of policy briefs to engage policymakers to continue to build on the success in four ways: incorporating desired elements from the Next Generation ACO model, primary care capitation, value-based insurance design, and addressing inequity in health care.

Aledade's retrospective case study, published in the American Journal of Accountable Care, compares the results of five Aledade MSSP ACOs to both ACO benchmarks and regional competitors over a four-year period. During this timeframe, "The cohort is estimated to have prevented 10,917 hospitalizations, 19,338 emergency department visits, and 8859 skilled nursing facility visits, compared with the region. This is believed to be largely driven by improvements in care transitions and preventive care, such as annual wellness visits, which the cohort of ACOs performed at 265% above the regional average in 2019."

The case study demonstrates that although results take time to achieve, value-based care has the potential to meaningfully reduce costs and improve the quality of care delivered by increasing preventive care and reducing utilization of acute services.

The pandemic created unprecedented financial challenges for the health care system and was especially difficult for primary care practices, who generally operate on slim margins under normal circumstances. Aledade advocated for independent primary care practices to be able to take advantage of the financial support from federal relief program rulings. We continue to ensure our partnering practices understand the telehealth landscape and additional flexibilities during the Public Health Emergency.

Showed CMS that Admission, Discharge, and Transfer (ADT) notices improve health and save money through compiling data and research, and broad advocacy. In March 2020, CMS included ADT notices as a condition of participation with Medicare under Medical Record services.

Regional benchmarking gives a more accurate picture of the savings ACOs provide to Medicare, and rewards ACOs that do a better job of controlling costs than their neighbors.