Our Take On The Adjustments CMS Made To Value-Based Models Due To COVID-19

The COVID-19 pandemic continues to wreak havoc on the American healthcare system. Creases or small tears in the fabric of our care delivery networks have been blown wide open. Traditional primary care is in the midst of an existential crisis as practices around the country struggle to pay the bills.

But not all news is bad. Sometimes crises give birth to positive changes. And we hope this is the case with the decision made by the Centers for Medicare and Medicaid Services (CMS) to proactively adjust the value-based models they have been piloting through their Center for Medicare and Medicaid Innovation (CMMI) to ensure that the new payment structures continue to work for providers, even in the heat of the pandemic.

Why the transition to value-based care is vital … even in the midst of a pandemic

We believe that the shift to value-based care is important, even as our system faces extraordinary stress. It’s the key to improving healthcare in the United States and better serving patients during the COVID-19 pandemic as well as future crises. Our experience at the beginning of the pandemic informs this opinion.

The payers that have implemented our advanced primary care model (a value-based model) were able to pivot their care delivery approach to not just survive the initial wave of COVID-19 cases, but also adequately serve all populations in the midst of the crisis. They did this by:

Investing in a primary care model that serves only their members, allowing them to make changes to their care delivery faster than the rest of the healthcare system at the beginning of the pandemic.

Utilizing a model in which both payers and providers are aligned on the primary goal of improving health outcomes and not simply completing procedures for the sake of reimbursement, allowing care centers to quickly switch to telehealth and virtual care options when the population’s needs demanded it.

Being able to be flexible about the response to the pandemic in which some care centers had to focus solely on COVID-19 but others were able to run split schedules where they served COVID-19 patients for a portion of the day and patients with other issues during the remainder of the day. Again, this was only possible because of a value-based model that focuses on health outcomes rather than the specific type of procedures or care that is provided.

Changes CMS is making

CMS Administrator Seema Verma announced the changes in an article in Health Affairs in early June.  In her announcement she said:

“Going forward, value-based care can help ensure health care resiliency. By accepting value-based or capitated payments, providers are better able to weather fluctuations in utilization, and they can focus on keeping patients healthy rather than trying to increase the volume of services to ensure reimbursement. Value-based payments also provide stable, predictable revenue— protecting providers from the financial impact of a pandemic.”

Verma’s strong and vocal support for value-based care is important. It’s vital for CMS to continue to push the transition to value-based care to build sustainability into our healthcare system. 

Among the guiding principles she mentioned for making changes to the value-based models was making sure that there were “sufficient financial incentives that encourage higher-quality outcomes,” “minimizing the reporting burden,” and making a commitment to “limit delays in new model implementation.” 

Now, it’s more important than ever that we support providers as they make the transition.

Some of the most positive changes to the value-based models will help providers participating in them to succeed. Likely the most important is CMS’s acknowledgement that this isn’t a normal time for anyone in healthcare, even if you’re operating within a value-based construct. With that in mind, they have modified cost targets and benchmarks so that providers and systems are able to cover the extraordinary extra and unplanned cost of responding to a global pandemic.

A moment not without peril

The news within the CMS announcement wasn’t all positive though. Verma noted that they were adjusting value-based model implementation due dates and extending the life of some of their existing payment models. These changes may not seem negative at first glance as they may allow some providers to continue down the path to value-based care albeit at a slower pace. Our concern is that they could have a negative impact long-term.

We’re now entering the sixth month of a pandemic that has no end in sight. CMS must remain committed to the transition to value-based care despite the unprecedented times we live in. This includes:

• Continuing to encourage providers and systems to make the transition despite the stressors on their payment systems.
• Ensuring that out-of-date, volume-based payment models are retired and do not continue to hang on because of this moment in crisis.

Where do we go from here

The COVID-19 pandemic has laid bare a simple fact. The time to transition to value-based care is now. And it must be done as quickly as possible. It’s the only way to implement a model with the agility and flexibility to respond to a crisis as serious as a global pandemic (putting aside for a moment other issues like shortages of PPE, etc.).

With the federal government locked in a stalemate on healthcare reform through at least the November election, it’s up to payers to make this move themselves. They can do this by partnering with us to implement our value-based advanced primary care model for their members.

To learn more about advanced primary care, download our eBook: Advanced Primary Care: The Front Line Of A Health Revolution.