The Centers for Medicare and Medicaid Services, healthcare organizations participating in value-based payment programs and patients would benefit if the agency were more successful at getting beneficiaries more involved in their own medical care.
When CMS's Center for Medicare and Medicaid Innovation first started its work on value-based care, top officials asked the agency to do so in the background, so that Medicare enrollees wouldn't notice any changes to their experiences with the healthcare system, said Dr. Mai Pham, a consultant who served as CMS' chief innovation officer under President Barack Obama.
"It was not a priority to make sure that they were informed about what's going on and, more importantly, giving them the opportunity to play a really meaningful role in improving care," Pham said.
Since then, the agency has learned that beneficiaries need a more prominent role in care management and treatment if value-based care is to improve health outcomes and lower costs. And while CMS has made some progress, the agency hasn't exhausted all its options, Pham said. Some of that is due to structural issues like outdated technological infrastructure and Medicare supplemental plans that aren't compatible with value-based payment. These obstacles make it difficult for CMS to engage beneficiaries through greater cost-sharing or other means.
Improving how CMS communicates with beneficiaries about value-based care could also help the agency achieve its goals. Few Medicare enrollees know anything about value-based care or how it affects them, experts said. Even when consumers get information about their participation in a value-based payment model and the importance of care management and coordination, it might only confuse them.
"It's a really hard concept for somebody who's not steeped in healthcare to understand. Half of them think it's a scam," said Eric Cragun, executive director of government programs at Salt Lake City-based Intermountain Healthcare's Castell. "It's really important for patients to know their benefits haven't changed."
Medicare enrollees also need actionable information to make informed decisions about their care, said Rob Saunders, research director of payment and delivery reform at Duke University's Margolis Center for Health Policy. "Consumers rarely have cost and quality information they can turn to," Saunders said.
Private insurers have been engaging their enrollees to manage costs and quality since the beginning, Pham said. As a result, they're further ahead.
"There are a lot of missed opportunities," Pham said.
For example, CMS could encourage insurers to tailor Medicare supplemental plans for ACOs, but it hasn't done so.
The agency could also ask all Medicare beneficiaries to identify their primary care providers on an ongoing basis. That make it easier to hold ACOs and participants in other value-based payment models responsible for a given beneficiary. This would also set an expectation among beneficiaries that someone is accountable for their health and get more of them engaged.
CMS has mostly left it up to ACOs to get patients to identify their primary care provider. But it's a lot of work for ACO participants, and they haven't had much success.
Instead, the agency has relied heavily on claims-based attribution to assign most patients to primary care providers, but it's not an ideal solution. "That captures at best 40% to 50% of a given PCP's patients," Pham said. "It dilutes the incentive for the PCP."
But the lack of beneficiary engagement in Medicare goes well beyond creaky technology and operational matters. CMS is also wary of getting in between patients and providers, Pham said.
"It feels like a big step politically to say, 'We expect everyone to have a PCP,'" she said. "I think that can be overcome because the reality is most people do."
CMS should do more research about what Medicare enrollees want and need, Pham said. For instance, some beneficiaries in the fee-for-service program might be willing to accept closed provider networks in exchange for incentive payments, but the agency hasn't looked into that.
"The agency is just making some assumptions about what beneficiaries think," Pham said.
Likewise, patients are developing different treatment preferences thanks to the recent increased adoption of telehealth and other alternative means of care delivery, but it's hardly reflected in traditional Medicare, 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. Navathe is a member of the Medicare Payment Advisory Commission.
Policymakers may need to reconsider the meaning of value-based care to increase beneficiary engagement in Medicare, Navathe said. Historically, value has been framed in terms of outcomes and costs because those issues are most important to the Medicare program and taxpayers. But as the healthcare system moves further toward value-based care, it will become increasingly crucial to take the individual beneficiary's perspective into account to ensure the program is delivering for them, he said.
Value-based care models designed to lower spending without improving quality might save Medicare money, but could make things worse for patients. For instance, joint replacement bundles and ACOs have decreased the use of post-acute care facilities like skilled nursing facilities to curb spending. But that could cause problems for beneficiaries who don't have caregivers or family members to help them at home, Navathe said. The innovation center won't capture all those effects when it evaluates its models.
"There might be a significant quality of life impact," Navathe said.
Mandating that value-based care providers do more to engage beneficiaries could also improve the innovation center's payment experiments, said Dr. Josh Liao, medical director of payment strategy at UW Medicine in Seattle. Existing models often allow ACOs and others to engage beneficiaries by educating them about managing chronic disease, offering self-care classes or increasing shared decision-making, but they mostly don't require it.
CMMI could further encourage participants in value-based care models to engage beneficiaries by giving them credit for the efforts when the agency evaluates their performance or by specifically designing models to create other incentives for them to do it, Liao said.