• In The Trenches

    Correcting CMS’ Suggested Correction for Value-based Systems

    CMS Administrator Seema Verma, M.P.H., recently wrote an op-ed wagging a stern finger at certain accountable care organizations and other alternative payment models she complains have underperformed.

    analytics chart, calculator, stethoscope

    The upshot of her piece is that too few value-based models have yielded savings reflective of the agency’s ambitions and should therefore be rethought — despite some of the most promising models arguably having only just emerged from their nascency. And make no mistake, the numbers Verma has in mind are hugely ambitious. She credits CMS’ 2018 Pathways to Success final rule as the foundation on which the Medicare Shared Savings Program built a miraculous-sounding (indeed, record-high, Verma writes) $1.19 billion in Medicare savings last year.

    Verma’s column is headlined “Correcting the course of value-based care models,” but the thing is, it doesn’t proceed from quite the right bearings. That’s the takeaway from the smart conversation that’s bubbled up in her argument’s wake.

    “Did the MSSP save Medicare $1.2 billion in 2019? No — not even close,” counter health policy experts J. Michael McWilliams, M.D., Ph.D.; and Alice Chen, Ph.D., in a Nov. 12 Health Affairs blog post. “Might the true net savings be close to zero? Quite possibly.”

    The rest of that post neatly unpacks the flaws in how Verma’s op-ed interprets CMS data. Equally critical, it also outlines why care must be taken when centering big decisions on big benchmarks.

    “Touting benchmark-based calculations as proof of program success despite countervailing evidence is not just harmless promotion,” McWilliams and Chen warn. Among the hazards of that math, they add, is the overselling of downside risk as “a game-changer” and the soft-pedaling of the parts of the MSSP that do need refinement.

    Later, in a short paragraph that deserves applause, they add: “Critics have often pointed to the modest net savings generated in the first few years as evidence that the ACO model ‘doesn’t work.’ This reflexive assessment is misleading and counterproductive to the policy debate. For several reasons, the MSSP is more accurately characterized as a program of great potential limited by substantial, but addressable, problems.”

    Jeff Micklos, J.D., executive director of the Health Care Transformation Task Force, also takes issue with how CMS is throwing around the B-word.

    “Verma’s suggestion about setting benchmarks lower and increasing discounts causes great concern,” he writes in a Nov. 11 Modern Healthcare opinion post. “Continually evaluating performance based on historic accomplishment is driving a race to the bottom, undermining the very strength of the American health care system. Moreover, the policy choice to evaluate models based on the average performance of all participants is masking the true success of those high-performing participants who have fully invested in and committed to these models.”

    Family physicians pioneering these models are finding success. And what we are learning from their example is that our real-world benchmark is time. There’s no single template for an APM’s best size, especially given that we want to end up with a significant, powerful network of such practices to meet a broad public’s broad needs while emphasizing continuous preventive care. The Academy’s support for APMs has always been driven by the belief that they lead to improved care coordination, better outcomes and lower costs while steering U.S. health care away from the increasingly problematic fee-for-service model.

    That’s why we’ve pushed CMS this year to expand the Primary Care First model. The Academy’s modeling has long predicted that PCF will operate better than the Medicare Quality Payment Program’s Merit-based Incentive Payment System, even for those getting the maximum MIPS bonus. The pandemic has brought into sharp relief how important it is for more family physicians to join this innovative system.

    With these priorities in mind, the AAFP also joined 17 other organizations last week to ask that Congress maintain the existing structure for incentive payments to APM participants. These payments have increased clinician participation in value-based care and — here’s the part Verma should appreciate — demonstrated savings for Medicare. Yet the thresholds for earning these payments are slated to increase to a level likely to be out of reach to many physicians, particularly those already affected by the COVID-19 pandemic. We’re asking Congress to freeze the thresholds where they are for the 2021 and 2022 performance years so that those physicians now in an advanced APM will continue to receive bonus payments.

    Not for nothing, we also believe that such a move will encourage further APM participation. That’s a correct course.

    Speaking of courses, I hope you’ll join the next AAFP Town Hall — 7 p.m. CT on Dec. 2 — for a discussion of the Academy’s advocacy plans now that the election is over. Expect to hear from Academy President Ada Stewart, M.D.; AAFP Senior Vice President for Public Health Julie Wood, M.D., M.P.H.; and my colleague David Tully, director of the AAFP’s Government Relations Division.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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