通往价值的曲折之路：了解每个市场中的VBC动态

February 2024 The winding road to value:2February 2024Understanding VBC dynamics in each marketThe Health Care Payment Learning and Action Network (HCP-LAN) developed a widely adopted framework for categorizing VBCagreements. A high-level overview of the framework, which was originally introduced in 2016 and refreshed in 2017, is shown in Figure1. The exact terms of payment models will certainly vary, but generally, as a provider moves along this continuum from Category 1 toCategory 4, they are taking on more financial risk for managing the care of the population. Value-based contracts that fall intoCategories 3 and 4 are considered risk arrangements or value-based contracts where providers take on financial risk for the quality andefficiency of care provided rather than reimbursement based on the volume of services provided.FIGURE 1: LEARNING AND ACTION NETWORK (LAN) ALTERNATIVE PAYMENT MODEL FRAMEWORKThis paper covers an overview of considerations for providers participating in VBCs in different markets that are essential best practicesfor succeeding with VBC arrangements.VBC contracts and strategies are different depending on the source of health benefit coverage. While there may be some similarities indesired objectives, there are unique considerations depending on whether the contract is for a commercial,3Medicare Advantage,Medicare FFS, or Medicaid population. Even within some of these markets, there are additional factors that need to be considered.There is rarely a one-size-fits-all solution to value-based care. In addition to each of these markets, there is a trend moving healthcaremarkets toward a more high-touch care model, which has been studied in senior populations4and is having an increasing impact in allfour of the coverage types considered in this paper.Also, while we have considered each market separately, providers should ensure they are viewing all VBC arrangements with abroader lens to ensure that the overall VBC strategy can be achieved as the details are worked out for VBC contracts more generally.3For purposes of this paper, we use the term “commercial” to include nongovernmental, full benefit health insurance, such as employer group coverage for active employeesand individual insurance through the ACA exchanges.4Ghany, R. & Tamariz, L. (August 28, 2018). High-Touch Care Leads to Better Outcomes and Lower Costs in a Senior Population.American Journal of Managed Care.Retrieved January 31, 2024, fromhttps://www.ajmc.com/view/hightouch-care-leads-to-better-outcomes-and-lower-costs-in-a-senior-population. The winding road to value:Understanding VBC dynamics in each marketMedicare FFSMARKET CONSIDERATIONSMedicare is a federally run program primarily providing healthcare coverage to people over age 65, though younger beneficiaries mayalso be covered by Medicare if they have qualifying disabilities or end-stage renal disease (ESRD).Under traditional Medicare, or what is often referred to as Medicare fee-for-service (FFS), providers are typically reimbursed based onpredetermined fee schedules developed by the Centers for Medicare and Medicaid Services (CMS). These fee schedules are updatedannually and can vary by geography and the complexity of the services provided. As of 2023, approximately 30 million Medicarebeneficiaries were covered by traditional Medicare (with close to the same number enrolled in a Medicare Advantage plan).As shown in Figure 2,6the percentage of the U.S. population eligible for Medicare has increased significantly over the last 15 years.FIGURE 2: PERCENTAGE OF PEOPLE COVERED BY MEDICARE IN THE UNITED STATES, 1990-2021Hastened by an aging population, the proliferation of value-based reimbursement models is a strong indicator that CMS believes value-based care should become a significant focus in the Medicare space in an attempt to shift financial incentives from service volume tocare quality, patient outcomes, and a reduction in the per capita cost of care.VALUE-BASED CARE TRENDSWhile the percentage of Medicare-eligible beneficiaries enrolling in Medicare Advantage plans continues to grow, traditional Medicarestill covers approximately 49% of the total eligible population, with a significant proportion of those dollars flowing through value-basedpayment arrangements with ACOs. The Medicare Shared Savings Program (MSSP) began in 2012 and has grown to includeapproximately 11 million Medicare FFS beneficiaries as of 2023.7The Realizing Equity, Access, and Community Health, or ACOREACH model, covers an additional 2 million beneficiaries. In addition to those two programs, the Center for Medicare and MedicaidInnovation (CMMI) continues to announce new programs, such as the States Advancing All-Payer Health Equity Approaches andDevelopment (AHEAD) model and the Making Care Primary (MCP) model.Growth in provider participation in value-based care arrangements, and ACOs in particular over the last decade (and the continuedpush in the coming years), has been facilitated by phy