CMS official: don’t expect many fully risk-based payment models in the future
Don’t expect much more entirely risk-based payment models from the Center for Medicare and Medicaid Innovation (CMMI), a senior official said.
Centers for Medicare & Medicaid Services COO Jon Blum detailed the agency’s vision for value-based care at the National Association of Accountable Care Organizations fall conference Thursday.
“I don’t think CMS will promote models that carry more risk just for the sake of having more risk,” Blum said.
While Blum said it’s always important to have risk-based models, there is some data that shows the downsides of full risk payment models.
“We know that when we [incentivize] risk that we see downsides to that, ”Blum said. “We are seeing stronger incentives for more diagnostic trouble code submissions, some of which might be appropriate, some not.”
Another concern is when you have “more transformation towards risk which tends to favor those who are better capitalized and can afford the risk,” he added.
The ACOs agree to assume a share of the financial risk and to respect the expenditure and quality criteria. ACOs that do not meet the criteria will have to reimburse Medicare, but will get a share of the savings if they do.
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CMS has offered payment models that require providers to take on a high degree of risk. However, one of those models, the next-gen ACO model, was discontinued by the Biden administration.
Blum said that doesn’t mean CMS won’t adopt any high-risk model.
“For models to have more risk where they really get better risk and better value and more fairness, we will celebrate that,” he said. “But when we see a risk that leads to some of the downside of the harm that results in inappropriate payments or skewed participation by those who can afford it, that’s a challenge for us.”
Blum also gave details of CMS’s vision for value-based care in the future, including a top priority of using payment models to address health equity gaps.
“We want the health care system to be much more equitable and we want to serve people better,” he said. “The team at our Innovation Center noted that the models we currently apply tend to involve higher income communities, which are disproportionately white. “
CMMI Director Liz Fowler, Ph.D., previously said that models may be required to collect and report data on race and ethnicity as a condition of participating in models.
Another key part of the agency’s overall vision is to simplify the number of models and leads available.
“We lost sight of our big picture,” Blum said. “We have a lot of different models, different flavors of what is shared savings and what is responsible care. I think in that spirit of trying to create more options, we’ve lost sight of what’s really close to our hearts. “
The agency is looking to simplify leads and options for vendors in the future.
“10 years ago the right course was to have many models to develop, but we are in a new phase where we want to put resources where we think we can get the most out of the learning and create a whole. more streamlined menus, ”said Blum, referring to the initial founding of CMMI.