2022 forecast: Expect CMS and CMMI to tweak payment models to boost health equity

The Biden administration is likely to make several changes to existing models next year to improve health equity rather than rolling out a new wave of models, experts and agency officials say.

The Center for Medicare and Medicaid Innovation (CMMI) released earlier this fall a new strategic vision for the next decade for value-based care, with health equity a major pillar. Providers will start to see the first signs of how this vision will be implemented in 2022, and advocacy groups are also pressing for changes to how accountable care savings are generated and how to participate in the Direct Contracting model.

“We will ask ourselves how this model affects equity … and what resources are needed including financial and human capital,” said Dora Hughes, M.D., chief medical officer with CMMI, which oversees value-based care payment models, during a summit Dec. 15 held by the Health Care Payment & Learning Action Network.

But providers and payers shouldn’t expect to see many new models launching in the next year, Hughes said.

“When we start to think about models, with the new models we are thinking about, the earliest they can be launched is 2023,” she said.

The center needs time to go through rule-making and comment periods before a model may be launched.

“It does take some time to get new models out the door,” she said.

RELATED: CMMI rolls out strategic refresh to make payment models more equitable and streamlined

Hughes emphasized that the duration it takes to create new models won’t deter its work to improve equity and that the center is looking at how to make changes to existing models.

One expert says CMMI and the Centers for Medicare & Medicaid Services’ (CMS') push for equity could change how providers are recruited for value-based care programs.

“Providers that focus on vulnerable populations or rural providers may not be able to participate in those models,” said Lauren Cricchi, a consultant with Avalere. “We may see them incentivizing or prioritizing those models to start participating.”

Hughes conceded that more safety-net providers are needed to participate in value-based care in order to reach vulnerable populations, and part of CMMI’s strategic refresh is to ease barriers to participation that include the high up-front costs for providers.

“We need to provide options and tools for providers to provide multiple levels of risk to bring into the fold,” she added.

CMMI and CMS also are pressing for providers to offer up data on health equity and social determinants of health that can inform future actions.

“The big thing is what does the data say and what impact can we make short and longer term,” said Cybil Roehrenbeck, a healthcare lobbyist and partner in Hogan Lovells’ government relations and public affairs group.

Advocates hope that CMMI doesn’t just tinker with existing models to improve equity but also to make it easier for providers to participate, including combating unnecessary overlap among models.

“Providers have definitely been very challenged by facing [alternative payment model] overlap,” said Allison Brennan, senior vice president of the National Association of Accountable Care Organizations (NAACOS), in an interview with Fierce Healthcare. “It has been incredibly confusing and has not been transparent and the rules are constantly changing.”

RELATED: ACOs need screening tools and new quality bonuses to help address health equity, NAACOS says

NAACOS is also hoping for changes to the Medicare Shared Savings Program, which oversees ACOs, primarily in how benchmarks for ACOs are set. Benchmarks are the quality and spending targets that ACOs must meet to qualify for shared savings.

“That is really important, because, while it is a technical and wonky issue, it is critical because it determines whether ACOs can be successful in earning shared savings,” she said.

Direct Contracting

While newer models may not be on tap for next year, CMMI is still taking steps to implement the expansive Direct Contracting model that enables providers to take on partially or fully capitated risk payments.

Provider interest in the model is particularly high, and the center could leave open new chances for them to sign up, Avalere’s Cricchi said.

The first performance year for Direct Contracting started in April. However, the center did not take applications for the start of the Jan. 1, 2022, period.

CMMI did enable some groups to sign up, such as those in the Next Generation ACO program that shutters after this year, but the center could create new application opportunities.

Extending MACRA bonuses

Experts are keeping a close eye on what Congress will do with expiring bonus payments under MACRA.

A 5% bonus for physicians that meet quality thresholds for alternative payment models is expected to go away after next year.

In addition, 2022 is the last performance year to get the 5% bonus and be paid the bonus in 2024.

NAACOS is hoping to get the bonus extended for another six performance years.

If the bonus payments go away, the incentive for physicians to sign up for alternative payment models will be “significantly depleted,” Roehrenbeck told Fierce Healthcare.