Value-based care leaders share tips for greater progress

Value-based care leaders believe bolstering primary care participation in alternative payment models and consolidating efforts within the Medicare Shared Savings Program are among the top ways to accelerate the shift away from fee-for-service.

In a new commentary in NEJM Catalyst, Farzad Mostashari, M.D., Sc.M., co-Founder and CEO of Aledade, and Geoffrey Moore, Ph.D., managing director of Geoffrey Moore Consulting, recommended five ways the Trump administration can make value-based care progress, which they say has plateaued.

"Progress is stymied because the things that attract early adopters and innovators are not the things that will entice remaining providers to make the leap from traditional fee-for-service payment models to value-based care," they wrote. "There is a chasm to be crossed as value-based care moves from being something that a relatively small number of forward-looking provider entities embrace to a default model that is widely adopted, thus becoming the new mainstream."

First, the current administration, through CMS, needs to start with primary care providers, according to Mostashari and Moore.

Primary care has the most pressing business case for adopting value-based care models considering the recent cuts to the Medicare Physician Fee Schedule, which has also been criticized as undervaluing the work primary care physicians do. Yet, only about 45% of primary care providers participate in Medicare accountable care organizations (ACOs), cited data from the American Medical Association revealed.

Tapping primary care providers as the next wave of adopters will help to make value-based care mainstream, Mostashari and Moore stated.

Second, CMS needs to define the competition, which is fee-for-service, in this case. Fee-for-service is problematic for the healthcare industry, at large, but particularly for primary care providers. The federal government must state that "unfettered fee-for-service is bad for beneficiaries and bad for Medicare (and will therefore be disincentivized for providers as well)."

Third, CMS "should focus on incremental improvements that address the reasons providers are resisting change." A major issue is that the pragmatic early majority adopters don't want the bells and whistles of value-based care but proven solutions, Mostashari and Moore explained.

The Medicare Shared Savings Program can address this issue because it is a permanent value-based program run by CMS versus the many alternative payment models run by the CMS Innovation Center, which appeals more to early adopters or innovators.

The Shared Savings Program offers a standardized pathway to value-based care. However, CMS must address longstanding challenges with the program, including benchmarking methodologies that tend to penalize cost-saving ACOs, and cash flow delays.

CMS has taken steps to solve these value-based care challenges, including cash flow problems through the new ACO Primary Care Flex Model.

Fourth, value-based care needs to be more than a CMS strategy; private payers need to be involved to accelerate progress. CMS can start by extending its accountable care goal--100% of Traditional Medicare beneficiaries in accountable care relationships by 2030--to Medicare Advantage plans.

Mostashari and Moore also advocated for value-based care contract standards and application processes across private payers to encourage participation outside of Medicare.

Finally, Mostashari and Moore suggested a greater role for "physician enablers" like Mostashari's company Aledade. Aledade is a network of primary care physicians in value-based care arrangements. It, and other physician enablers, provide scalable services and manage ACOs for physicians.

"We distinguish enablers from other ACO service providers in three primary ways: they actively recruit practices into the ACOs they manage, provide executive leadership to the ACO, and share in savings with the ACO participants," they explained.

These five strategies can help the federal government make value-based care mainstream after stymied efforts to shift away from fee-for-service. The general sentiment around value-based care is positive, with many stakeholders recognizing its opportunities to improve care delivery and reduce costs.

However, fee-for-service is deeply entrenched in the healthcare system. Most healthcare payments across public and private payers were either fee-for-service or fee-for-service with a link to value in 2023, according to the Health Care Payment Learning & Action Network's latest numbers.

The Trump administration also recently ended four alternative payment models early. The Primary Care First, End-Stage Renal Disease Treatment Choices, Making Care Primary and Maryland Total Cost of Care models will all end after 2025.

CMS also indicated it is considering reductions to the Integrated Care for Kids model.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.