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Health systems, accountable care organizations and other operators are largely responsible for engaging providers in value-based care, as CMS policies and programs aren’t especially prescriptive on that front. The agency could help clinicians buy into value-based care by simplifying its programs, improving information sharing, designing clinician-centric models and holding healthcare organizations more accountable. But that could be easier said than done. “Culturally, it’s hard for CMS because the agency has a real aversion to getting in between provider relationships,” said Dr. Mai Pham, a consultant who formerly served as CMS’ chief innovation officer. Healthcare executives have complained for years that it’s difficult for them to redesign care delivery around CMS’ countless payment policies and programs, each with their own quality measures, reporting requirements and financial rewards and penalties. “The incentives are often counterproductive and conflicting with each other. It makes it hard to manage and know how to enter into value,” said Dr. Robert Fields, chief medical officer for population health at Mount Sinai Health System in New York. Not only has that created problems for the C-suite, it’s also made it tougher for clinicians to understand how their actions affect their organizations’ performance in value-based contracts. CMS could alleviate some of those issues by adopting simpler, more cohesive payment policies across original Medicare, Medicare Advantage, Medicaid and other programs. It could also align its value-based payments with commercial insurers to get more providers on board and accelerate the transition from volume to value. The agency’s leadership seems keenly aware of the issue and is likely to address it. “No other payer comes close to matching the influence wielded by our agency, and many payers follow our lead,” said Liz Fowler, director of CMS’ Center for Medicare and Medication Innovation, during a Health Affairs event in June. “And that means that we are in a unique position to be a healthcare disruptor and a driver for change. We take that responsibility very seriously.” A greater focus on non-financial interventions could also make payment reforms more effective. The agency hasn’t really experimented with demonstrations that incorporate the lessons of behavioral economics, such as how information is delivered to providers. For instance, in most CMMI models, providers receive performance-based financial rewards or penalties long after they deliver care, which can make them less effective. “We are expecting clinicians to change their practice on January 1 of the performance year, but they don’t see the impact of that behavior until April of the following year. That’s not a good design,” said Dr. Amol Navathe, associate director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania’s Perelman School of Medicine. He’s also a member of the Medicare Payment Advisory Commission. Greater cooperation among hospitals and health systems could also make it easier for everyone to give their providers more real-time information about their patients. The new interoperability rule requires Medicare providers to make information available about patient admissions, discharges and transfers. But it’s still difficult for health systems to get that information, which makes it harder to engage providers in value-based care. One of the secrets to getting providers more engaged is to show them how value-based care solves their pain points. But providers often don’t see the benefits in their practice thanks to administrative hurdles that make it difficult to take advantage of additional flexibilities, especially when it comes to CMMI’s alternative payment models. While healthcare organizations may want to use every available waiver at the start, they quickly realize that they only have so much bandwidth to put them into practice. That’s mostly due to the complexity of disparate medical events, application processes and compliance requirements. In reality, providers often can’t use the new tools in their toolbox. “You don’t see a lot of these flexibilities implemented,” said Robert Saunders, research director of payment and delivery reform at Duke University’s Margolis Center for Health Policy. Including clinicians in the design process and creating programs built around the way clinicians think and do their work could help the agency achieve better results, Navathe said. “If we design models in a clinician-centric way, we can use the same dollars to incentivize the right behavior and get more behavior change,” he said. “The non-financial attributes of these programs have been undervalued in terms of how much they matter and why we’re not getting the results that we’re seeking.” The agency could also work on finding new ways engage specialists because they often have fewer ways to participate in value-based care compared with primary-care providers. “There are few models that really focus on and are designed for specialists,” Saunders said.
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