away from FFS will be forced to reconsider their involvement
in value-based payment models.
The Advantage of MA
To overcome these obstacles, at least in the federal sector,
AMGA members increasingly are turning to Medicare Advantage (MA). As opposed to the federal accountable care
organization (ACO) programs, MA is less burdensome and
does not have the patient attribution issues that plague some
ACO models. AMGA members indicated that newly eligible
Medicare beneficiaries increasingly are selecting MA to
receive benefits that are not available in FFS Medicare. Conversely, provider interest in federal ACOs may have plateaued.
Programmatic rules, patient attribution concerns, and the
financial benchmarks that determine if an ACO earns shared
savings or must pay a penalty limit the opportunity for providers in ACO models to succeed financially.
AMGA and its members remain optimistic about the transition
to risk. Despite the slowdown in the transition and the barriers
to accepting downside risk, 60% of survey respondents indicated they would be able to enter into downside risk products
within two years. To aid in this transition, AMGA has several
policy recommendations that would improve the ability of providers to practice under value-based payment:
Impediments to Taking on Risk: Federal/Commercial
4. 4 5
4. 3 4. 3 4. 2 4.0 4.0
3. 6 3. 6 3. 5 3. 3 3. 3 3. 1 3.0
4. 3 4. 3 4. 2 4. 1 3.7
3. 4 3. 2 3. 2 3. 2 3. 1 2. 9
Congress should require federal and commercial payers
to provide access to all administrative claims data to healthcare providers.
To aid providers in submitting their data to federal and commercial payers, Congress should mandate standardized data
submission and reporting processes.
Given the million-dollar investments in infrastructure
needed to be accountable for a patient population in a
downside-risk model of care, providers should be allowed to
use income on a tax-free basis if used in making the needed
upgrades or to offset losses in risk-based contracts.
Demands from local employers, payer networks, and federal policies, as well as financial incentives aligned with the
group practice delivery model, create a rationale for providers
to pursue risk-based contacts. Additionally, AMGA and its
members recognize that relying on FFS models of care and
reimbursement is not a viable long-term strategy.
While there is agreement across the industry that health
care needs to embrace value-based care delivery and payment
models, providers cannot be expected to be solely responsible
for that transition. If health care truly is to be rooted in value,
payers and other stakeholders must have similar incentives to
embrace value-based care.
Darryl M. Drevna is director, regulatory and public policy at AMGA.