The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has kept up a steady stream of new model announcements over the last several months, leading providers deeper down the road of value-based payments and bearing risk.
The new models include the Direct Contracting and Kidney Care Choices models. These models are designed to provide greater flexibility and incentives to align providers and transform care than previous models.
The Direct Contracting model aims to build on the experience of the Medicare Accountable Care Organization (ACO) models to create the next generation of risk arrangements by incorporating elements of primary care and total cost of care capitation.
The Kidney Care Choices model includes the Kidney Care First and Comprehensive Kidney Care Contracting models, which are the next evolution of the Comprehensive End Stage Renal Disease (ESRD) Care model structure and are designed to incentivize better management of chronic kidney disease, ESRD, home dialysis and transplantation.
The Direct Contracting and Kidney Care Choices models include capitated payment and two-sided risk arrangements.
Capitation unshackles providers from a fee-for-service mindset to deliver care in new and innovative ways. Capitation also requires:
- Streamlined and effective clinical operational models.
- Sophisticated high-value provider network and incentives strategy.
- Advanced financial modeling and analytics.
- An enhanced approach to patient activation.
The key to participants’ success is a strong learning system that enables participants to make informed decisions that accelerate and optimize performance in the models.
Premier is working to do just that. We are honored that the Centers for Medicare & Medicaid Services (CMS) and research firm Mathematica have selected Premier to support content development for the CMS Value Based Care Learning system. This new learning system will facilitate peer-to-peer learning among Direct Contracting Entities (DCEs), Kidney Contracting Entities (KCEs) and Kidney Care First practices.
In collaboration with CMS and Mathematica, our team of experts will deliver thought leadership and curriculum development, and implement shared learning vehicles that rapidly disseminate leading practices to support participating providers. Providers will benefit from a dynamic curriculum that uses feedback from model participants to respond to evolving learning needs and policy issues.
The learning system activities embody the work Premier has been leading for more than a decade with hundreds of healthcare providers in our collaboratives – connecting providers, data and knowledge to accelerate progress and outcomes.
It’s a proven methodology: Hundreds of providers participating in Premier’s other collaboratives regularly outperform national standards and deliver cost savings and innovation, including in our Population Health Management Collaborative, Bundled Payment Collaborative, QUEST and in our new contract with the U.S. Department of Health and Human Services’ Office of Women’s Health to leverage our data and collaborative methodology to scale maternal health improvements nationwide.
Key Capabilities Participants Need to Advance in Innovative Payment Models
Capitated and two-sided risk models allow providers the freedom to deliver innovative care, but the risk of failure is real and consequential. Providers in alternative payment models need to build off core capabilities already in place, while also considering development of new clinical, technical and administrative functions.
Here are four essential capabilities they should aim for:
1. Streamlined and effective clinical operational models. These are essential to perform at advanced levels of risk. Providers must:
DCEs and KCEs will need to optimize their operational structure to develop economies of scale for both capital and operating costs.
2. A sophisticated high-value provider network and incentives strategy. The aim here is to drive care transformation and deliver cost savings at greater levels of risk.
The financial arrangements offered in Direct Contracting and Kidney Care Choice models provide an opportunity to develop downstream risk sharing and sub-capitation incentive models, which can include creative quality and efficiency bonuses and provide regular cash flow to physicians much sooner than in shared savings distributions. Given the heightened opportunities and risk, high-value networks should include:
- Primary care, specialist, post-acute care, ancillary and ambulatory providers
- Community partners
- Social services
- Behavioral health providers
Capitation also provides the freedom for providers to undertake activities that better coordinate beneficiaries’ care for which the fee-for-service system does not currently reimburse them. KCEs will also need to closely integrate transplant and home dialysis providers to support the patient journey across the renal continuum.
3. Advanced financial modeling and data analytics. In all two-sided risk models and particularly in models with capitation, entities will need to:
- Evaluate and benchmark the effectiveness and value of investment of clinical interventions.
- Establish interoperability between providers to exchange clinical data, coordinate care and manage leakage.
- Integrate electronic health record (EHR) clinical data with claims information to target performance improvement, conduct population segmentation and measure and predict performance over time.
4. Strategies, resources and education for beneficiaries and training for care teams. These activities and tools are essential to effectuate next-level patient activation, particularly in Kidney Care Choices. KCEs must have a strategy to engage patients early in their renal care trajectory regarding treatment choices and modalities, including transplantation and home dialysis.
KCEs will also be measured on patient activation measures, and both KCEs and DCEs will need a strategy to address patient experience of care, given the elevated importance of those measures. Voluntary alignment is also an opportunity to observe tangible benefits from a strong patient engagement approach.
The Skills to Test, Innovate and Scale
Participants that join advanced alternative payment models have the opportunity to lead the nation in value and population health strategy. These models challenge participants to disrupt care delivery, evolve risk-sharing arrangements and set an example for how to improve quality, experience and costs for beneficiaries.
The work excels and innovation is born when participants have a proven, data-driven partner – and a network of peers – standing behind them.
Learn more about Premier’s population health collaboratives and all the ways we bring providers together to safely reduce costs, generate shared savings and improve outcomes.
The insights you need to stay ahead in healthcare: Subscribe to Premier’s Power Rankings newsletter and get our experts’ original content delivered to your inbox once a month.