To get more doctors to embrace value-based payments, the CMS wants to team up with states to launch multi-payer efforts that could qualify as alternative payment models under the Medicare Access and CHIP Reauthorization Act (MACRA). But some state officials may see the initiative as too closely linked to the Affordable Care Act.
Last week, the CMS issued a request for information (PDF) from states on what they would need to implement APMs. Responses to the document are due Oct. 28.
The information will inform the next iteration of CMS' State Innovation Models (SIM) initiative, which provides financial and technical support to develop and test multi-payer healthcare payment and service delivery models aimed at delivering better quality of care at a lower cost, not only for Medicare, Medicaid and Children's Health Insurance Program (CHIP) beneficiaries, but for all residents of participating states.
Since 2013, SIM has supported efforts in over 38 states, territories and the District of Columbia.
Given the financial incentive and the fact that states are actively trying to reduce healthcare spending, they will likely be interested in this new opportunity, said Trish Riley, executive director of the National Academy for State Health Policy.
In the RFI, the CMS asked for ways to enhance the role of Medicare in multi-payer models. That's an attractive proposition for states, given the amount of Medicare beneficiaries and the fact that federal statutes make it difficult to tie the program to local efforts, Riley said.
But because SIM, which is overseen by the Center for Medicare & Medicaid Innovation, is a product of the Affordable Care Act, politics may cause some states to pass on the opportunity, according to Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, a national coalition of health care providers.
“State officials would say there's too much financial risk at stake for our state, but the real reason is political ideology,” Nielsen said. “They aren't interested in any type of partnership with the federal government that insinuates support for the Affordable Care Act.”
There's also little evidence that alternative pay models improve quality and cut costs, according to Kip Sullivan, a health policy expert and member of the Physicians for a National Health Program, a not-for-profit that advocates for universal, comprehensive health coverage through a single-payer plan.
Last week, the CMS released an evaluation of some of the longest-running SIM efforts and the report concluded that it was too early to determine whether the SIM initiatives have changed provider behavior or improved care coordination, care quality and population health.
That finding, coupled with reports that accountable care organizations and medical home demonstrations fail to cut costs provides little incentive for states to respond to the RFI, Sullivan argued.
It's also unclear whether physicians are interested in participating in any new APMs. MACRA already requires physicians to participate in the new Merit-based Incentive Payment System (MIPS) if they do not have a substantial amount of their revenue at risk under a qualifying APM. Thus far, the vast majority of physicians say they do not.
A CMS report released last week found states are having trouble getting providers to buy into payment reform because they are fatigued by the multiple, concurrent delivery and payment reform initiatives.
But the CMS' recent concession that allows providers to pick their pace to comply with MACRA gives providers more time to consider joining an APM that may launch in their state, according to Josh Seidman, senior vice president at Avalere Health.
A key strategy to getting providers to switch to a new APM will be ensuring reporting requirements are less burdensome than those under MIPS, Nielsen said.