Commonwealth Fund 6/9/2021

There are several evidence-based, promising approaches for holding health care accountable that CMMI should consider:

1. Physician-led ACOs. Physician-led accountable care organizations (ACOs) have been one of the most successful payment reforms tested in the past decade, although gains have often been modest. Physician-led ACOs have an advantage over those led by hospitals: physicians, unlike hospitals, do not have incentives to keep beds full and are thus more open to less-costly approaches to meeting patients’ needs. CMMI can build on progress and accelerate adoption of physician-led ACOs by combining levers for accountability and perhaps making participation mandatory. CMMI could offer more powerful financial incentives, apply prospective payments for defined populations to increase predictability for providers, incorporate accountability for equity, and require community representation on governing boards as a condition of participation. Further, ACO models could be supplemented with evidence-based bundled payment models, which engage procedure-oriented specialties and are easier to implement than comprehensive population-based models in organized delivery systems. When implemented with ACOs, bundles are more likely to be coordinated with other care and incentives to increase volume are reduced. ACOs also could include full or partial primary care capitation to promote coordinated, population-based care at the front lines.
2. Geographic models. Geographic-based models of accountability have shown promising results. CMMI could consider expanding these approaches, applying different levers to ensure accountability for total cost, quality, and equity of care for defined populations in specific jurisdictions. As with ACOs, the models could incorporate capitation or partial capitation of primary care providers who are best positioned to provide cost-effective and critical services like care coordination and prevention.
3. Home-based care. Comprehensive home-based care models, particularly those serving the homebound or people with complex health and social needs, have created meaningful improvements for patients, along with lower Medicare costs. CMMI could expand successful programs like Independence at Home, increase accountability among home care agencies, and encourage the provision of home-based care in other accountability models. Health plans (either Medicare Advantage or Medicaid managed care) or ACOs, together with the provider teams delivering comprehensive home-based care, could be jointly accountable for cost, equity, and quality of care.
4. Medicare Advantage plans. CMMI may consider using the Medicare Advantage (MA) program as a key target for expanded accountability. One drawback is that some MA plans compensate providers on a traditional fee-for-service basis, thus failing to incentivize them to devise more cost-effective treatment plans. CMMI could test requirements for MA plans to delegate risk and resource-allocation decisions to clinicians as a way to promote joint responsibility for cost, equity, and quality of care. CMMI could then consider reviewing and improving the star rating system to ensure higher ratings are associated with better care and greater equity.

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