May 29, 2024

Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Ave, SW
Washington, DC 20201

Re: Medicare Program; Request for Information on Medicare Advantage Data

Dear Administrator Brooks-LaSure,

On behalf of Accountable for Health, we appreciate the opportunity to provide comments on the Medicare Advantage data request for information (RFI). Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.

Our recommendations related to driving accountable care for Medicare Advantage relationships with providers include:

  • The Administration should expand its accountable care goals to include Medicare Advantage, adding that 100% of Medicare Advantage beneficiaries be in an accountable care relationship by 2030.
  • CMS should consider incentives to health plans corresponding to the MACRA incentives to providers to encourage the adoption of accountable care relationships to support these goals; and
  • CMS should provide more transparency around the APM data that is currently collected from plans to measure progress against the 2030 goals.

Background

Across payers, accountable care has demonstrated that it can improve care and lower costs. In Medicare Advantage, recent evidence shows that accountable care arrangements between payers and providers can improve quality, such as reducing unnecessary hospital admissions, avoidable Emergency Department admissions and preventable readmissions.1

We encourage the Centers for Medicare & Medicaid Services (CMS) to continue to build on these successes by encouraging the adoption of more accountable care relationships in Medicare Advantage.

The Health Care Payment Learning and Action Network (LAN) measures adoption of alternative payment models by line of business. The LAN categorizes payment types as follows:

  • Category One – fee-for-service with no link to quality arrangement to include arrangements where payments are based on volume of services and not linked to quality or efficiency.
  • Category Two – includes fee-for-service with a link to quality to include all arrangements where at least a portion of payments vary based on the quality or efficiency of health care delivery including hospital value-based purchasing and physician value-based modifiers.
  • Category Three – includes alternative payment models built on fee-for-service architecture to include all arrangements where some payment is linked to the effective management of a population or an episode of care. Payments are still triggered by delivery of services but there are opportunities for shared savings or two-sided risk.
  • Category Four – includes population-based payment arrangements to include some payment that is not directly triggered by service delivery so volume is not linked to payment. Under these arrangements, clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., greater than a year).

In Medicare Advantage, a large percentage of payments downstream from Medicare Advantage plans are in alternative payment models – 57.1% in categories 3 and 4. However, 38.2 percent of payments remain in category 1.<sup>2</sup> In comparison, in traditional Medicare, a smaller percent of payments, 41.4%, are in categories 3 and 4; but only 15.9% are in category 1.

The Biden Administration has articulated a goal of moving 100% of traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries to accountable care relationships by 2030. Accountable for Health recommends that Medicare Advantage be included in these accountable care goals, by explicitly adding to the goals that 100% of Medicare Advantage beneficiaries be in an accountable care relationship by 2030.

Creating Parallel Incentives for Medicare Advantage and Traditional Medicare

The Medicare Access and CHIP Reauthorization Act (MACRA) created a system of incentives to move providers in traditional Medicare to greater levels of accountable care. Specifically, MACRA included a 5% bonus for providers who participated in advanced alternative payment models (two-sided risk arrangements that met certain criteria). These incentives have created significant movement to advanced APMs in traditional Medicare, including a 25% increase in such models from 2021 to 2022, with now over 400,000 clinicians participating in advanced APMs.

MACRA also created an all-payer option that would allow providers to count their risk contracts in Medicare Advantage toward their participation in advanced APMs, allowing those clinicians to qualify for the 5% bonus on their Part B claims by pooling their risk arrangements from traditional Medicare and other payers, including Medicare Advantage. However, to date, no provider has qualified for the 5% bonus using their other payer arrangements through the all-payer option.

In our view, there are two main reasons for this lack of participation in the other payer category. First, plans were required to disclose contract elements to the federal government, which proved too burdensome. Second, the incentive for participation in this disclosure did not flow to the plan, it flowed directly to the clinician in the form of a bonus to the clinician as a percent of their Part B claims. Due to the configuration of this all-payer option, very few payers participated in the other-payer option under MACRA and all clinicians who qualify for the bonus today qualify only through the traditional Medicare avenue.

To create a stronger incentive to increase risk arrangements for both clinicians and plans across traditional Medicare and Medicare Advantage, we recommend creating harmonized incentives across both programs to move along the LAN’s progression to categories 3 and 4. We encourage the agency to create as much alignment to the MACRA incentives for advanced APMs as possible to ensure that there is consistency across Medicare in moving providers to greater levels of clinical and financial accountability.

Provide Greater Transparency Around APM Information Plans Submit

Medicare Advantage plans are currently required to report data aligned to the LAN categories one through four on their payments to providers to the Centers for Medicare & Medicaid Services (CMS). We note that plans also report this data to the LAN through their associations. CMS has indicated that the data plans report will help determine how broadly Medicare Advantage organizations are using alternative payment arrangements.3

Looking ahead, we recommend that CMS provide greater transparency around the data that plans are reporting on their adoption of APMs. Sharing this information regularly will create greater visibility into the scope of existing APM participation and continue to drive change toward the 2030 goals.

Conclusion

Accountable for Health appreciates the opportunity to weigh in on the data transparency request for information. Please do not hesitate to contact us with questions.

Sincerely,
Mara McDermott
CEO
Accountable for Health

1 Cohen, K. et al, Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs. Fee-for-Service Medicare Programs (JAMA 2023).
2 https://hcp-lan.org/workproducts/apm-methodology-2023.pdf
3 https://www.cms.gov/files/document/cy2024-part-c-technical-specifications-02222024.pdf

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