Premier Inc. executives survey the APM landscape, at a time of change

Premier Inc. executives survey the APM landscape, at a time of change

Where is the whole population health management/value-based health care bandwagon going? Two executives very involved in values-based health, in different spheres, have concrete ideas. Healthcare Innovation Editor Mark Hagland recently spoke with Melissa Medeiros and Seth Edwards of Charlotte-based Premier Inc. about the range of issues, challenges and opportunities in these areas. Medeiros is senior director of policy and government affairs and Edwards is vice president of population health and values-based care at Premier. Below are excerpts from their lengthy interview.

Melissa, tell me what areas of politics you cover at Premier?

Melissa Medeiros: I oversee value-based care, quality measures, and everything related to Medicare.

And what are the main concerns for you right now?

One of our top priorities is for advanced incentive payments which are due to expire at the end of the year, so we are pushing for an extension of these policies. MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] involves 5% bonuses for clinicians involved in advanced APMs [advanced payment models]. And by 2022, there is currently a two-year lag in the payment of these bonuses, between the year of payment and the year of performance. These have been essential for our advanced APM vendors. There is a lot of concern about the loss of incentives for people who move on to advanced APMs, or for those already involved, who keep moving forward.

Which APMs are affected?

The MSSP [Medicare Shared Savings Program] is the most important, but only certain practices are eligible. Suppliers participating in the ACO REACH model and bulk payments are also eligible. Some leads are eligible. The bonuses are intended for physicians and other clinicians.

Is this your main political objective at the moment?

This is one of our main areas of interest at the moment. We held a joint briefing on the Hill with APG [America’s Physician Groups] and NAACOS [the National Association of ACOs], Last week. We work closely with them. And that briefing focused on value-based care broadly, with an extension to some of the specific APMs.

Seth, what are you most involved in right now?

Seth Edwards: Much of the work we’ve done has been to help organizations develop their population health strategies, and to do so in the environment and paradigm where organizations are seeing significant cost increases in supply and labor costs. best way for the hospital or the COA to move forward? If we can avoid readmission for heart failure, one of the most expensive – and most readmissions are now low or zero margin events – then we can really help these organizations. So it’s about streamlining the delivery model to make sure you’re doing what’s best for organizations and the community, but also making sure you’re doing what’s best for the long-term health of the entire health system.

Can you comment on the fact that this could be a particularly difficult time to embark on value-based contracts for provider organizations that have remained in fee-for-service until now? As we all know, the pandemic has caused great financial hardship for patient care organizations, especially hospitals and health systems, in terms of revenue, so their margins are much thinner than they appear. were two and a half years ago.

In fact, I think it’s an optimal time to take advantage of what we hope will be finalized in the physician fee schedule. Now is a good time to look at the margin challenges they face under Medicare and move forward. And according to the Kaufman Hall quarterly reports that you referenced, if you say, look, we’re losing money on every admission to Medicare, how long will that negative margin persist, and how long will the costs of staff continue to increase? Isn’t this talking about moving forward with value-based contracts. If you enter MSSP and can share the savings, it can give you renewed margin. So this is a great time for organizations that have largely focused on hospital care, which can move forward to become truly integrated healthcare delivery systems; we call it sustainability. I don’t think there will be more money in health care. And as prices are forced down and reimbursement continues to decline, working in new ways to support value-based care delivery is the time.

Medeiros: We see CMS putting policies in place to attract new vendors into value-based programs. The administration is currently focusing a lot on offering new flexibilities. We even saw new opportunities for advanced investment payments for smaller providers who lacked experience in value-based care. Hopefully we will see some of these policies finalized early next month, when we expect the physician fee schedule to be finalized.

Edwards: And as CMMI pursues the goals that they set out in the 2030 vision document that they released, if everyone is going to be in a responsible Medicare model by 2030, it’s really incumbent on organizations to go forward ; because if you don’t move forward in a responsible relationship with Medicare, you will be commodified to other organizations. For me, this offers a real opportunity.

Where are your members having the most difficulty?

Edwards: We work with about 70 organizations in our population health collaboration. Some groups are just getting started; others have been working in this space for 20 years. But the most common request from each of them is: can we help them develop a strategic roadmap, or a risk maturity model, that helps the organization conceptualize how quickly it should move risk in each of the paying sectors? Medicare, Medicare Advantage, commercial insurance and Medicaid, and direct contracts with the employer. So when looking at each of these payer segments, they need to decide how quickly to move to risk, and what capabilities are required to succeed at each stage, and how they factor in market system and payer readiness. – the desire to implement a maturity model. It is therefore a question of developing this strategy and planning carefully. Significant care management support is needed—the infrastructure to manage the population; and that includes technology and analytics. We do a lot to help organizations understand their data, as well as develop strategies around complete and accurate documentation and coding.

How will things evolve in the next five years?

How will things evolve in the next five years? There will be a number of groups, depending on the outcome, the physician fee schedule, and how the Medicare Advantage market is adjusting to emerging from the public health emergency. It also depends on how the industry reacts to that—because they’ve had some benefit from reduced reporting requirements; this could impact MA payment down the road. Some of our members will likely move to high risk levels. In general, as you take on more risk, you also have more upside opportunities. They’ll believe there’s an opportunity out there

Providers say they learn from Medicare Advantage and it helps them take double-sided risks in Medicare.

Yes, many of our members learn this way, but many organizations are committed to risk with health plans, through joint ventures, partnerships, or contractual elements involving shared savings. So I think that’s going to be a trend we’ll see, groups looking to take on more risk, to solidify their margin pressures. There are groups that use their experiences in the area of ​​upside risk only to gain experience and integration with their clinicians, to keep moving forward in double-sided risk. But I believe there will really be a doubling, due to the possibility that they may be trivialized.

One of the points of tension between CMS [the Centers for Medicare & Medicaid Services] and vendors, under the previous administration, exceeded MSSP program benchmarks, which vendors deemed too difficult and the details of which, for example, NAACOS leaders said would drive many vendor organizations out of the MSSP . Seema Verma insisted that providers take bilateral risks faster than many wanted.

Medeieros: We were all pleasantly surprised by what was offered by CMS last year; there has certainly been a change in mentality between administrations. There seems to be less emphasis on progression to risk, as happened with Pathways To Success, which potentially pushed people into bilateral risk too quickly for them. There seems to be an awareness of concern that if ACOs continue in the program, there could be a race to the bottom, where they compete with their previous success, according to benchmarks. We have provided comments on this. They seek to establish a set of administrative benchmarks for five years; we urged them to work with stakeholders. I love the RFIs from this administration; I think they’re listening, and the old physician fee schedule has shown some flexibility.

By this, the proposed rule came out in July; we expect the final rule to drop around 1 November I believe to come into effect in calendar year 2024 so we should have a better idea of ​​where things are headed by early next month . But I think some of the requirements could be implemented gradually. And also, given past economies, this is a policy that people have been asking for for some time; that affects the sustainability of the MSSP. There has certainly been a shift from administration to administration.

Edwards: I agree, a change is afoot. And it seems to be less about putting organizations at risk quickly and more about getting more organizations involved. This will only increase the number of organizations interested in participating, as well as maintain their current participation.

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