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MULTI-PAYER ALIGNMENT ON VALUE-BASED CARE DISCUSSION HIGHLIGHTS

During a meeting with experts on the implementation of multi-payer alignment on value-based care, various stakeholders, including the Center for Medicare & Medicaid Innovation (CMMI), shared their perspectives and engaged in a discussion on the critical steps necessary for transformation. Below is a summary of the multi-stakeholder perspectives and the discussion. For more information on the meeting’s content, please see the full Discussion Proceedings of this meeting in Appendix B. The meeting agenda and invited attendees are featured in Appendixes E and F.

• The landscape of multi-payer alignment and value-based care. David Muhlestein, Leavitt Partners, noted that despite several promising multi-payer state-led initiatives underway, such as Arkansas’s experience with a multi-payer bundled model or Vermont’s experience with the Accountable Care Organization model, there is substantial heterogeneity in the payment ecosystem’s goals, processes, and progress among payer quality measures, benchmarking, payments, reporting, and transparency. Additionally, patient, provider, purchaser, and payer relationships have become more complex and multi-directional, leading to stakeholders pursuing their individual interests without accounting for unintended consequences, such as higher care costs or the continued dominance of fee-for-service health care. Furthermore, there is misalignment between payment approaches and benefit design and the complex delivery of clinical and pharmaceutical interventions to treat diseases such as cancer. Therefore, CMMI could act as a central fa-

• cilitator converge stakeholders around common goals to prioritize patient and beneficiary interests. It is also a priority for CMMI to increase the adoption of its alternative payment models (APMs) through a comprehensive engagement strategy that involves Medicare, Medicaid, private payers, and other relevant stakeholders from the point of listening sessions and consultations toward model development, demonstrations, evaluation, and adoption. Moving forward, CMMI could first clarify its statutory authority to work with payers to co-develop models, discuss negotiated rates, and ensure alignment to drive increased adoption of value-based care models. CMMI could then work with other stakeholders around common goals to achieve greater care value and multi-payer alignment. Through these relationships, CMMI could also increase the adoption of the Centers for Medicare & Medicaid Services’ (CMS’s) Core Quality Measures to track field progress, build stakeholder accountability, and ensure public reporting and transparency.
• Patients, families, and communities. Fee-for-service payment arrangements incentivize the provision of high-cost, low-value care that neglects beneficiary interests. To tackle the economic dominance of fee-for-service payments in provider and payer market share, CMMI could intervene in ten selected markets to increase the competitiveness of value-based care models. CMMI could also require providers to submit payer mix information across multiple payers over a five-year time horizon. During the succeeding five years, providers would be assisted and encouraged by CMMI to move toward serving 60-80% of patients through value-based care models. CMMI could also demonstrate the critical importance of meaningfully engaging stakeholders to codesign, disseminate, and implement value-based care models. In this intervention, CMMI would convene and support multi-stakeholder community tables utilizing evidence-based and data-driven approaches. These groups would have the authority to address the impacts of major crises such as COVID-19, structural racism, adverse childhood experiences, and the opioid crisis while investing in evidence-based and

• health-related investments and resources such as behavioral health services, affordable housing, social services, and criminal justice reform.
• States. At the state level, the COVID-19 pandemic’s challenges demonstrated the resilience and effectiveness of providers in value-based payment (VBP) arrangements. States like Pennsylvania leveraged their convening and purchasing power to increase the adoption of VBP models in Medicaid, state employee plans, public sector purchasing collaborative for unions, teachers, local governments, and certifying Qualified Health Plans in the state marketplace. Pennsylvania is also considering enhancing payment value and tightening cost controls by redefining the right value of services and procedures. CMMI could help states by providing greater clarity around metrics and data collection and an implementation roadmap to achieve patient-centered equitable care.
• State policy. Across a broader cross-section of states, a National Academy for State Health Policy (NASHP) focus group consisting of 400 state leaders found that while states are major purchasers, they need employers and CMS to drive markets toward value-based care models. Additionally, successes in states such as Vermont, Maryland, and Pennsylvania could not be directly replicated due to the misalignment and variation of payers, providers, beneficiary populations, state governments, and CMS efforts between states. States also require CMMI guidance on best practices in collaborating with payers and employers, as well as future clarity on whether workforce-related COVID-19 regulatory flexibilities will remain. Furthermore, the federal government and CMMI could most meaningfully engage states by leveraging their current priorities of health equity, the social determinants of health, and behavioral health. Finally, CMMI could reduce the difficulty and requirements of model adoption by building upon the success of the Comprehensive Primary Care Plus model.
• Payers. Payment structure was also cited as a cross-cutting requirement and driving factor for purchasing value-based health and health care. The current fee-for-service domi-

• nated landscape embeds providers with reputational, patient volume, financial and unit price advantages, thereby providing little incentive for providers to transition toward value-based care models. Furthermore, value-based care models have failed because unit price increases often outstrip savings generated from decreased care utilization. Attendees suggested CMMI focus on improving their models and efforts to provide more compelling incentives, payments, and performance relative to fee-for-service payment arrangements. Within the federal government, CMMI could amend regulations and policies in Medicare Advantage plans, the U.S. Department of Defense’s TriCare, the Affordable Care Act’s exchanges, and the Veterans Health Administration to shift purchasing of health care for federal employees toward value-based care models. In the broader field, CMMI could emphasize priorities such as value and health equity by reallocating capital toward investments supporting health systems serving underserved communities and providers with a higher proportion of beneficiaries covered by value-based care model.
• Purchasers. Attendees also raised that in order to combat fee-for-service dominance, progress on payment reforms would require mandates, credible business threats, and contract changes that require value-based care. Attendees suggested that CMMI work with external entities that can increase CMMI’s capacity by testing models at scale and collaborate with purchasers, groups, and community organizations that have achieved progress in aligning incentives and payment systems. CMMI could assess markets by readiness for value-based care model implementation, provide personalized technical assistance, and share commitment and risk through requiring matching funds from market participants. They suggested CMMI set health outcome targets; utilize patient-reported outcome measures; require data stratification by race and ethnicity; and reauthorize the Network of Quality Improvement and Innovation Contractors with an updated Clinician Quality Improvement Contractor Clinician-Focused Task Order. Finally, attendees urged

• CMMI to track and report value-based care performance metrics by adapting the Health Value Index developed by the Purchaser Business Group on Health.

OPEN DISCUSSION

• The discussion began by acknowledging the work of the Healthcare Payment Learning and Action Network (HCP-LAN) to inform CMMI’s shift toward advancing national and regional primary care models, aligned economic supports, direct contracting, Primary Care First, population accountability, and health equity actions.
• Attendees emphasized that current model incentives are weak, limiting adoption across providers, states, and payers. CMS could design value-based care models to reward behavioral change or form a coalition of employers, communities, providers, and states to prioritize value. As a solution to limited state adoption of value-based care models, an attendee suggested that CMMI provide implementation assistance to states with large rural areas and lower patient volume.
• Furthermore, models do not intervene significantly in the daily lives and realities of beneficiaries. To this end, the social drivers of health were suggested as a top priority for CMMI. For example, an individual with diabetes who is food insecure costs $4,413 USD more per member per year than a person with diabetes who is not food insecure, and that 38% of the geographic variation in Medicare spending is attributed to social drivers in unadjusted models. APMs are currently insufficient in meeting social needs because they incentivize, reimburse, or support providers and practices to address these drivers by screening for social needs, navigating patients to services, or reimbursing community organizations that could meet these needs. Therefore, CMMI and relevant stakeholders, such as commercial payers and providers, could incentivize and leverage additional investments in community assets and social infrastructure to close resource gaps impacting health outcomes, such as low food access.

• However, more evidence and case studies from the CMMI State Innovation Model grants are needed to inform social risk adjustment and financial modeling methodologies. CMMI could collaborate with the CMS Office of the Actuary to collect data needed to clarify financial modeling methodologies. As an example of the social drivers of health implemented in practice, CMMI could utilize North Carolina’s multi-stakeholder social drivers of health infrastructure, navigation, and payment pilot.
• Despite the importance of CMMI’s ultimate goals for health systems transformation, it cannot resolve every issue. Instead, the focus could be on defining a core set of health measures, reducing the total cost of care, and enhancing patient health and health care experiences with a focus on states where value-based care models have had limited impact due to their rural geographies, lower patient volume, and less competitive marketplaces.
• CMMI could also provide guidance and operational clarity on the competencies and requirements to implement value-based care models successfully. As a complement to care value and quality, CMMI guidance on common data elements, operational requirements, and data for community health information exchanges would help clarify regional differences in cost benchmarking and engagement with commercial payers and employers.
• Additionally, CMMI could further engage with employers who are willing to experiment with value-based care models because of the impacts of the COVID-19 pandemic and their demand for real-time health care access with digital options and data responsiveness. Furthermore, rural communities have also experienced the damaging impact of fee-for-service health care. To address this issue, employers can work with CMMI to leverage their significant market size, leadership, and infrastructure to shift regions toward value-based care models and practices.
• In addition to major private and state employers, multi-payer alignment on value-based care can be achieved at the state level. In this context, state governments can utilize

• their convening and purchasing power to align Medicaid, Medicare, public employees, private payers, and public exchanges. This convening power could first rally stakeholders, resources, and the workforce in negotiating more attractive reimbursement rates for value-based care, achieving common performance indicators and benchmarks of provider performance and beneficiary health outcomes, and optimizing resources toward improved care quality and population health outcomes. The ultimate goal, attendees agreed, would be to center and prioritize beneficiary health through improving health outcomes, promoting equity, and reducing the total cost of care.