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Policy Forum Series: Rethinking Federal Policy to Advance Payment Reform

Recap and Next Steps

On May 12, C-TAC hosted the 2021 National Policy Forum that focused on key issues of the C-TAC Policy Agenda. The first panel “How to Leverage Federal Policy to Advance Home- and Community-Based Care Models” featured Anne Tumlinson, CEO of ATI Advisory, and Dr. Mona Siddiqui, Senior Vice President, Clinical Strategy and Quality, Enterprise Clinical Management at Humana. 

Background  

Americans need a system of care that supports families living with serious illness. To achieve this, we need to reboot federal policy on healthcare payment reform, especially where delivery models are concerned. The Center for Medicare and Medicaid Innovation (CMMI) was established as part of the Affordable Care Act to promote healthcare innovation and accelerate the shift to a value-based healthcare system. CMMI has had some promising results, but more must be done to fulfill its mission, especially in regard to care for those with serious illness. Specifically, the shift to value-based payment must accelerate, especially for traditional fee-for-service Medicare, the payer for most Medicare beneficiaries. 

Federal payment reform is essential to improving serious illness care. The legacy fee-for-service model focuses narrowly on medical benefits and is not designed to deliver the holistic suite of services people with serious illness need. Fee-for-service Medicare does not pay for the full interdisciplinary team or the wraparound social services that are key components of high-quality serious illness care. And some of the value-based models that CMMI has tested or is testing—Medicare Care Choices and the VBID Hospice Carve-in—reach only a small population and do not cover a comprehensive and well-coordinated set of services. 

Key Takeaways 

  • Payment reform must reduce the burden on family caregivers, and be mindful of the extensive work families are already undertaking 
  • Substantial upfront investments in operational infrastructure are preconditions for successful delivery and reimbursement of innovative care models 
  • Many smaller community organizations are already generating a lot of savings to the healthcare system, but are not able to capture that value due to logistical challenges in partnering with large risk holders like Medicare Advantage plans. A special pathway for small organizations to take risk—like that available to PACE programs—may be needed. 
  • Care models need to be tailored to the type of health setting in which they are deployed. Successes and lessons learned may not translate across different settings. 

Personal Insights 

  • I was the primary caregiver for my grandmother in the final weeks of her life. She was a really strong woman who, had I not intervened, would have spent her last few weeks in the hospital instead of in the home. – Dr. Siddiqui 
  • Caregivers’ primary concern and frustration is the degree to which they are saddled with clinical care in the home…We have to be very careful to keep the needs of the family in mind because they are already doing a lot. – Anne Tumlinson 

Strategies for Successful Payment Reform 

  • “You can’t focus on efficiency and disruptive innovation at the same time,” explains Tumlinson. Transforming the healthcare system to emphasize value requires substantial upfront investment. CMMI’s mandate to achieve savings over a short time horizon has limited their ability to be truly transformative. 
  • New care models need sufficient time and certainty to succeed. As a payer that has already embarked on the journey to a value-based system, Humana has learned that substantial upfront investments in operational infrastructure are necessary to launch new care models. Private organizations cannot make these kinds of long-term investments for a time-limited model with an uncertain future, the standard arrangement of CMMI experiments to date. 

Next Steps 

Policymakers need to move away from a focus on short-term, scattershot experiments, and instead commit to a longer-term and more strategic approach. In other words, CMS needs to be more intentional about the future direction of reform for the program. To advance new care models for people with serious illness, federal policy needs to provide for four conditions of success: 

  1. A long and predictable time horizon 
  1. Flexibility 
  1. Scale 
  1. Substantial upfront investment 

Fortunately, policymakers are not flying blind. In determining this strategy, CMS can build upon everything that has been learned from the experiments of the past decade, including models work that C-TAC and some of its members have developed. 

To hear more insights on barriers and opportunities for home- and community-based care models, listen to the full presentation at the 2021 C-TAC National Policy Forum website. Please visit the website to learn more about the C-TAC Policy agenda.  

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