Future of Value-Based Care, Role of Alternative Payment Models

François de Brantes is senior vice president of Episodes of Care at Signify Health and has been designing and implementing value-based payment programs for over a decade. For Signify Health, he leads customer development of Medicare Advantage, self-insured employer, and commercial payer markets. In this interview, Mr de Brantes discusses alternative payment models, advancing value-based care, and the Center for Medicare and Medicaid Innovation’s (CMMI) refreshed strategy and future goals.

Can you comment on the Center for Medicare & Medicaid Services (CMS) CMMI’s refreshed strategy on equity and accountability?

The strategy refresh offers both important introspection on past and current models and several important recommendations for the future, including how to get close to 100% of Medicare beneficiaries in accountable care relationships and addressing the current level of inequities in beneficiary outcomes.

The goal of 100% is important and nuanced in the sense that it recognizes that being in an accountable care relationship means a Medicare beneficiary has at least one of their main providers of health care engaged in an advanced alternative payment model (APM). That can be the primary care provider (PCP), a specialty care provider, a hospital, or health system. This implies, and the strategy refresh is explicit about this, a portfolio of advanced alternative payment models that can engage different providers organizations into taking financial and clinical accountability for their Medicare beneficiaries.

What are the requirements for successful implementation of APMs?

The strategy refresh does a great job at outlining the challenges in existing models and lays out specific recommendations for the successful implementation of advanced APMs. The most important is the requirement to change the way in which the targets are set for any provider participating in an APM. The targets or benchmarks as they are commonly known are often adjusted at the beginning and end of a performance period, which means that a participating provider can experience a shift in their benchmark at the end of the performance period relative to what was set at the beginning.

That practice creates significant uncertainty that leads providers to drop out.

The other common practice is to reset the benchmarks very frequently which is akin to resetting the goal posts and making the ability to achieve savings increasingly difficult, which leads to participant drop out. Fixing these practices, making benchmarks fairer and more stable will make implementations more successful.

Can you discuss what is necessary for advancing value-based care in 2022 and beyond?

We need to engage with a lot more providers, and we also need to make sure that commercial health plans increase the volume of care that they pay as advanced APMs. That includes Medicare Advantage plans as well as those that administer employer-sponsored plans.

There need to be APM options for a variety of providers, as is proposed in the strategy refresh.

Today, most models either focus on PCPs or hospitals and health systems. Specialty care providers are often left out besides a few surgical specialties, such as orthopedics.

We need to make sure that the models are designed in such a way that they can succeed. Some best practices on model design were outlined in an article in the New England Journal of Medicine Catalyst.

Can you elaborate on the need to double down on APMs that facilitate providers taking on risk?

The Health Care Payment Learning and Action Network has created a taxonomy for APMs. The goal is to increase the number of APMs in categories 3b and beyond because those are 2-sided risk arrangements and are far more effective at driving value in health care. Today, only a minority of APMs are in these categories and that is why the transformation of the delivery system has been slow. So, we do need to double down on APMs, but on the right APMs.

What are the major implications for specialty and smaller providers?

Specialty care providers are central to the transformation of health care to value-based care. Unfortunately, there is a dearth of APMs for specialty care providers and hence the observation and recommendation by the CMS Innovation Center in its strategy refresh to change that and introduce new models that would appeal to specialty care providers.

Over the past 5 years several organizations—conveners—have emerged to support smaller providers and help them keep their independence. This is another critical element in the transformation of the delivery system—we must get as many providers engaged in APMs as possible without causing more provider consolidation than currently exists. Conveners can aggregate smaller providers without consolidating them into a single organization.

Can you talk about CMMI’s goal to get every Medicare beneficiary in an accountable care plan by 2030?

The goal is to get all Medicare beneficiaries into an accountable care relationship. That means having at least 1 of the beneficiary’s providers engaged in an advanced APM. Achieving that goal by 2030 is very ambitious and will require putting into practice all the elements mentioned in my prior responses.

About François de Brantes
François de Brantes serves as senior vice president of Episodes of Care at Signify Health. He leads customer development of the Medicare Advantage, self-insured employer, and commercial payer markets. He has spent close to two decades working to transform the US health care system by improving incentives for providers and consumers in order to encourage value-based decisions.

Prior to joining Signify Health, he served as vice president of Altarum, a national nonprofit. From 2006 to 2016, he was executive director of the Health Care Incentives Improvement Institute, a not-for-profit company that designed programs to motivate physicians and hospitals to improve the quality and affordability of health care delivery. The organization, which merged with Altarum in December 2017, was responsible for the Bridges to Excellence® and PROMETHEUS Payment® programs, which compensate and reward clinicians that focus on episodes of care and performance measures.