Provider advocates plan to push for policies to support more value-based care during the 2017 legislative battle to replace the ACA.

Dec. 8—Medical groups and integrated delivery systems are slowing their shift toward value-based payment, according to a new survey, even as federal alternative payment models are expected to undergo changes under the Trump administration.

Revenue continued to shift from fee-for-service (FFS) to value-based payments in 2016 among 168 medical groups and health systems that responded to a member survey by AMGA, a medical group trade association. The share of respondents’ federal revenue that came through FFS dropped from 45 percent in 2015, according to a previous survey, to 40.7 percent in the new survey. The share of revenue garnered from commercial FFS payments declined from 78 percent in 2015 to 77.3 percent in 2016.

However, the general shift came amid indications that FFS payments will make up a larger percentage of revenues in the next three years than was predicted in the 2015 survey. For example, survey respondents projected last year that by 2016, 68 percent of commercial revenue would come from FFS, an ambitious forecast compared with the 77.3 percent actual figure.

Additionally, expected revenue from more advanced risk-based arrangements, such as shared-risk and partial- or full-capitation agreements, was “significantly” less than predicted in 2015.

Donald Fisher, PhD, president and CEO of AMGA, said in a media call that “the transition to risk is slowing, and there are very real obstacles in the way.”

Although the two surveys mostly included different organizations, the survey report noted that both sets of respondents “represent leadership in very large and complex organizations, and their answers can be relied upon to paint an accurate picture of the risk-bearing landscape and provide a reasonable basis for comparison.”

Other worrying signs for proponents of value-based payment included a decline in the share of respondents’ commercial payer revenue from shared-risk arrangements (5 percent of revenue in 2015, 4.4 percent in 2016). However, a larger percentage anticipated they would be ready to take on shared risk within the next two years.

“So our members are getting more ready, while facts on the ground appear to be slowing down,” Chester Speed, vice president of public policy with AMGA, said in the media call.

Positive signs for advocates of value-based pay included an increase in the share of federal revenue received through various types of accountable care organizations (ACOs) from 11 percent in 2015 to 15.2 percent in 2016.

Overcoming Obstacles

As described in the survey, obstacles preventing more practices from increasing their reliance on value-based revenue included the low number of commercial insurers that offer such contracts and the infrequent sharing of administrative claims data.

Among steps AMGA urged Congress to take to help was enacting requirements that insurers provide access to all administrative claims data and that data-reporting processes be standardized, and allowing Track 1 Medicare Shared Savings Program ACOs—which are the vast majority of Medicare ACOs—to qualify as advanced alternative payment models (APMs). Qualifying as APMs would allow participating physicians to garner a 5 percent annual incentive payment under Medicare’s new physician payment system.

Members of Congress have been receptive to AMGA’s requests to require that insurers provide claims data and to bolster commercial insurers’ value-based payment offerings, Speed said.

“Obviously the state of play is the ACA [the Affordable Care Act] and what happens there, but there are going to be some significant opportunities for general healthcare issues and MACRA changes later on in the year, I believe, which is when we would attempt to put this in legislative language,” Speed said.

Federal Value Focus

On Dec. 8, the Centers for Medicare & Medicaid Services (CMS) proposed two new payment models aimed at increasing patient engagement in care decisions by giving Medicare beneficiaries more information, according to a CMS blog post.

The Shared Decision Making and Direct Decision Support models will test different approaches to shared decision making.

“These models will look to move beyond current practices and examine new ways to engage with patients with regard to their health and health care, and hopefully increase quality of care delivered, increase patient satisfaction, and provide value in the cost of care delivered,” wrote Patrick Conway, MD, principal deputy administrator for CMS, and Andy Bindman, MD, director of the Agency for Healthcare Research and Quality.

The federal government’s efforts to push more providers to adopt value-based payment are expected to continue under the incoming Trump administration. However, some important changes could be included.

Mark Weller, a partner at Dentons and a former legislative director for Sen. Richard Lugar (R-Ind.), said at a Dec. 7 briefing that the Trump administration and GOP-led Congress were expected to continue to support Medicare’s use of ACOs and bundled payment models, for instance.

Some observers have noted that the U.S. Department of Health and Human Services (HHS) may move away from mandatory bundled payment models under Rep. Tom Price (R-Ga.), whom Trump nominated as secretary. That expectation stems from Price’s explicit call for CMS to discontinue use of mandatory models, such as the proposed Part B drug pilot.

It is also unclear whether a potentially more consumer-directed focus for Medicare will undermine payment models that patients usually don’t know they are a part of. In addition, GOP leaders have announced their intention to push for a premium support approach for Medicare enrollees, which would move the program from a defined benefit to a defined contribution.  

Despite an expectation ACOs will get support, Jeff Hamling, a senior managing director at Dentons and former deputy chief of staff for Price, cautioned that there is potential for large healthcare policy shifts as Republicans seek to replace the ACA, which means ACO leaders need to communicate their successes to members of Congress to avoid having those programs be targeted for elimination.. Such advocacy also could help eliminate some of the logistical barriers that have impeded ACOs’ success, such as concerns about drawing antitrust enforcement.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare







Publication Date: Friday, December 09, 2016