Physicians, through the Colorado Medical Society, are uniquely positioned to drive this work
by Kate Alfano, CMS Director of Communications
Featured in the February-March-April 2023 Colorado Medicine Colorado Medicine.
Years of work developing current policy and driving advocacy initiatives related to health care value are now leaving the planning stages and entering execution. This work has largely focused on three areas:
- Expanding coverage and increasing competition,
- Enhancing the value of care through delivery and payment system reforms; and
- Targeting administrative burdens that inappropriately deter care, drive costs and decrease physician professional satisfaction.
The Colorado Medical Society has been active on multiple fronts to ensure we advance and defend physician priorities within these areas. In alternative payment models (APMs) alone, there are five different initiatives that have affected or will affect Colorado’s health and health care landscape for years to come.
1. APM Alignment Initiative
Starting in spring 2021, multiple Colorado state agencies joined the Office of Saving People Money on Health Care in the lieutenant governor’s office to investigate the feasibility of developing a multi-payer statewide APM to align payers’ efforts to shift away from fee-for-service payments to value-based payments – aiming to reduce administrative burden for providers, increase health care value, and improve quality and health equity for consumers – starting with maternity care and primary care.
The subsequently formed Colorado APM Alignment Initiative concluded its advisory work and released a final report in June 2022. CMS, joined by our colleagues in the House of Medicine, submitted a letter that outlined our recommendations focusing on aligned quality measures, common attribution and risk adjustment methodologies, and performance benchmarking, among others – many of which were incorporated into the report with the help of member physicians who participated in the initiative.
One physician who participated in the primary care subgroup is Christie Reimer, MD, an internal medicine physician in Fort Collins. “Learning about APMs feels overwhelming,” she said. “It’s an ‘alternative’ payment model so, by definition, it’s new and different, and that can feel scary. Achieving multi-payer alignment that includes public and commercial plans both locally and nationally is so very complicated. And we know that primary care will be playing a central role.”
Reimer continued: “My participation in the primary care subgroup felt therefore somewhat reassuring because the discussions were familiar and patient-centric: Initially there was agreement that an APM ‘continuum’ was important in order to meet providers, groups and systems where they and their unique patient populations are, and that common metrics should be aligned to minimize reporting burden. Conversations around defining those quality measures focused on things that we primary care physicians already do – for example, cancer screening, immunizations, depression screening, patient satisfaction and well care. In addition, routine updating of these metrics so that they remain evidence-based and relevant was felt to be important. Lastly, the idea that we need to focus on whole-person and team-based care came through, and there was recognition that we may need support with education, data management, and prospective payments.”
2. HCP-LAN STC
Colorado was one of four states – along with Arkansas, California and North Carolina – chosen in December 2021 by the federal Centers for Medicare and Medicaid Services to participate in the Health Care Payment Learning & Action Network (HCP-LAN) State Transformation Collaborative (STC) initiative to advance value-based payments in health care and accelerate the implementation of multi-payer APMs.
In a Dec. 21, 2021, news release, Kim Bimestefer, executive director for the Department of Health Care Policy & Financing, said: “Alternative payment models help health care providers move from volume-based payments to value-based payments. They also align compensation with the achievement of shared affordability and quality results, including reducing health disparities which is a priority goal for our state. This partnership with LAN underscores the importance and efficacy of paying for outcomes, shown by our existing value-based programs in maternity and primary care.”
3. HB22-1325 Primary Care APMs
House Bill 22-1325 Primary Care APMs was passed by the 2022 Colorado General Assembly. The Colorado Division of Insurance (DOI) will promulgate rules for primary care APM parameters for primary care services offered through health plans by Dec. 1, 2023. The Colorado Medical Society, guided by the physician volunteers comprising the CMS Committee on Value in Health Care, provided formal feedback on the draft bill in a letter on Feb. 1, 2022, and provided additional feedback and recommendations as the bill evolved.
APM parameters must include transparent risk adjustment parameters that ensure primary care providers are rewarded for caring for patients with complex health conditions; utilize transparent patient attribution methodologies; include a set of core competencies around whole-person care delivery that primary care providers should incorporate in practice transformation efforts; and require an aligned quality measure set that carriers and providers are engaging in under current state and federal law.
The Colorado Primary Care Payment Reform Collaborative (PCPRC) is continuing its work to develop strategies for increased investments in primary care that delivers the right care in the right place at the right time, and the PCPRC was specifically directed by HB22-1325 to publish a report with recommendations to the DOI regarding primary care APM parameters by Feb. 15, 2023.
5. Value-based payments in Medicaid
The Colorado Department of Health Care Policy and Financing (HCPF) is continuing its work to implement and align value-based payments in Medicaid. Among HCPF’s 2023-24 budget requests is HCPF R-06: Supporting PCMP Transition with Value Based Payments, which includes a 16 percent increase to reimbursements for Medicaid primary care physicians by enrolling in the Alternate Payment Methodology Two (APM 2) value-based payment program. Initial feedback from the Colorado Academy of Family Physicians (CAFP) and American Academy of Pediatrics – Colorado Chapter has highlighted some positives and negatives.
On the positive side, they identified that HCPF incorporated prior feedback about the need for incentivizing per-member-per-month (PMPM) payments and how important it will be to support practices who are still readying themselves for transitioning to value-based payments. HCPF also includes an opt-out for providers who still need more time or are not interested in value-based payments at this time.
On the negative side, there is still a great need to improve the patient attribution process and standardize training across Regional Accountable Entities (RAEs) to ensure consistency.
“Colorado Medical Society members should know that APMs are part of an ongoing and specific effort of both public and private payers to move health care delivery from a volume- to value-based reimbursement model,” said CMS past president Michael Pramenko, MD, a family physician in Grand Junction. “For example, we see this in the growth of Medicare Shared Savings Program (MSSP) and Medicare Advantage (MA) models for Medicare that are increasingly using APMs within their contracts.”
“It is important for primary care physicians to know about APMs as they become a greater percentage of their overall reimbursement,” Pramenko continued. “In addition, many practices need to understand that some APMs come in the form of shared savings. Given that these payments are not paid until the following year, cash flow can be an issue. Participating in the design of APMs is critical for primary care physicians’ practices.”
David Keller, MD, a pediatrician and University of Colorado School of Medicine faculty in Aurora, advises primary care physicians to deploy organizational skills they may not have had to maintain a revenue stream under APMs: monitor and report on measures of quality and outcomes; assess and modify care systems to provide and measure performance; coordinate care in a proactive and cost-effective way for the patients that the payer believes are under your care through some method of prospective or retrospective attribution; and become adept at managing a new kind of risk – not the risk of malpractice, but the risk of population outcomes for your attributed patients.
Alan Kimura, MD, an ophthalmologist in Denver, advises specialists to deploy tactics to commit to value and know how to demonstrate it: start tracking and improving your Net Promoter Score (asking patients if they would refer the practice to a friend or colleague), use financial data and clinical outcomes to generate the unique value proposition of your practice, and practice sharing this value proposition with payers as you renegotiate contracts. “Simply submitting bills for payment without demonstrating value (outcome/cost) is camping out at the ‘complacency barrier,’” Kimura said.
Seizing opportunities to protect and advance physician priorities through these initiatives requires active engagement by practicing physicians and CMS is uniquely positioned to drive this work. Real world, clinical, “bedside” perspectives and expertise are critically needed as these programs are developed and operationalized.
Reimer said: “It would be great to have a crystal ball to see how we will be practicing in the future, but the next best thing seems to be learning as much as we can and actively participating to shape health care delivery in a way that is best for our patients.”
Special thanks to Amy Berenbaum Goodman, JD, former CMS senior director of policy, and Jennifer Armstrong, CMS program manager for government affairs and communications, for their research for this article.
Health care cost landscape: Additional forces at play
Medicare reimbursement rate cuts
Congress failed to prevent end-of-year Medicare cuts and now physicians will face a 2 percent cut in Medicare payment in 2023 when they are already struggling due to the pandemic and rising inflation that is impacting the cost of providing care. When the same fight comes up next year, Congress must do more than simply reduce the planned cuts. Physicians need financial stability that includes automatic, positive, annual updates that account for rising practice costs.
Medicaid reimbursement adjustments
A line item in HCPF’s budget request, R-07: Provider Rate Adjustments, includes an across-the-board rate increase of 0.5 percent (with exceptions), but would also make targeted rate adjustments to bring reimbursements either up to 80 percent of Medicare or down to 100 percent of Medicare. The rate adjustments are based on the Medicaid Provider Rate Review Advisory Committee (MPRRAC) recommendations released on Nov. 1, 2022.
Medicaid’s Accountable Care Collaborative Phase III
Stakeholder meetings will begin soon to assist HCPF with program development for Accountable Care Collaborative Phase III, which will begin in July 2025 when RAEs will begin new contracts.
Potential efforts to amend the Colorado Option
Critical rulemaking on Colorado Option standardized plan revisions, the public hearing process, and rate setting is underway. Carriers have been contracting with providers for their standardized plan networks and Colorado Option plans will become effective in 2023. There is always a possibility that the law can be amended in rulemaking or by the Colorado General Assembly, and CMS is actively monitoring and participating in discussions.
Categories: Communications, Colorado Medicine, Cover Story, Resources, Practice Evolution, Payment Reform, Health System Reform