AHCA CEO: Value-Based Care ‘Most Exciting’ Development of His 30-Year Skilled Nursing Career

by Paul Bergeron

Skilled nursing providers are facing an extremely challenging operating environment, but they must keep adapting and innovating as the shift toward value-based care continues across the U.S. health care system.

And in fact, providers have tremendous opportunities to seize.

“Value-based care through the population health management model is the most exciting thing I’ve had the chance to be a part of in my 30 years in the industry,” said Mark Parkinson, CEO and president of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), at the organization’s recent Population Health Management Summit.

To succeed, skilled nursing providers must understand the definition of value-based or accountable care, educate staff, and consider the various models that provide paths forward.

And federal agencies driving the creation of value-based care models are aware of the importance of skilled nursing facilities and the role that SNF providers can play in reducing fragmentation of care, said Ellen Lukens, deputy director of the Center for Medicare and Medicaid Innovation (CMMI).

A person-centered approach

The Centers for Medicare and Medicaid (CMS) has set a goal that by 2030 all Medicare Part A/B beneficiaries will be in a care relationship with accountability for quality and total cost of care.

While that basic principle of accountability — lower overall costs while improving care quality, through a more integrated care delivery paradigm — has remained consistent, the updated definition of accountable care puts the patient at the center, emphasized opening keynote speaker Mark McClellan, a former CMS administrator sho is currently director at the Margolis Center for Health Policy at Duke University.

Specifically, McClellan said, the definition “centers on the patient and aligns their care team to support shared decision-making and help realize the best achievable health outcomes for all through equitable, comprehensive, high quality, affordable, longitudinal care.”

When educating staff members about accountable care, McClellan stressed that providers “must put it terms that they can understand, or it won’t get done.”

McClellan highlighted some specific elements of the definition to zero in on, including:

• care teams must work together over time and across practice areas to support patient needs
• care teams must go beyond traditional medical services to improve outcomes and health equity, which is gaining a greater prominence as a goal

In short, accountable care is “about more than payment reform.”

Of course, changes in payment mechanisms are a major component of value-based care, and Medicare Advantage (MA) is one major facet of this trend.

Through MA, private-sector insurance companies gain greater flexibilities to manage the health of their patient populations — with institutional special needs plans (ISNPs) specifically designed for people residing in nursing facilities. One leader in the ISNP space is American Health Plans, and CEO Michael Bailey recently spoke about the successes of this model — and the need to think even bigger — at Aging Media Network’s recent CONTINUUM conference.

A Kaiser Family Foundation (KFF) report forecast that Medicare Advantage enrollment is projected to surpass traditional Medicare by 2025. During multiple sessions at the AHCA Population Health conference, it was estimated that currently the country is at about 60% to 70% enrolled.

“Medicare Advantage (MA) continues to adopt leading reforms in moving away from FFS payment – while extending the MA models to additional diverse and rural populations, which may create challenges in continuing this trajectory,” McClellan said. “ … Medicare Advantage plans and the Health Care Payment Learning and Action Network (LAN) are committed to working together to find the best ways to continue to learn from and extend these important Alternative Payment Model (APMs).”

McClellan said that in traditional Medicare, new programs are being implemented in 2023 that are likely to accelerate progress – including Medicare REACH (an advanced, LAN Category 4 program with a special emphasis on addressing health equity), and new advance payments for smaller, rural and safety-net providers shifting into accountable care, among other steps.

He said that while many states are in the process of adopting systemwide accountable care reforms, some Medicaid and safety net providers face continuing challenges with taking on risk and accountability for comprehensive care.

Provider input needed to drive innovation

The Center for Medicare and Medicaid Innovation wants to hear more from “those on the ground” about “how you think about the future of care and how it can be incorporated into our models,” Lukens said at the conference.

Lukens discussed what her organization is planning in its look ahead to population health management, including continuing to reexamine ACO benchmarking approaches and working across CMS and LAN to measure accountable care.

CMMI is continuing to embed health equity in its model design, implementation, evaluation, and through technical assistance, tools and resources for model teams and participants, Lukens said.

Specifically, CMMI will work to refine approaches to incorporate screening and referrals for social needs and to evaluate the impact of models on underserved populations.

Data sharing and benchmarking is a core component of value-based care, and lack of interoperability is a major hurdle to overcome, providers said at CONTINUUM, and Lukens also highlighted tech-focused efforts at the AHCA event.

CMMI aims to adopt modern standards for data consistency, such as Fast Healthcare Interoperability Resources (FHIR). The agency will also release data for additional models in the CMS’ Virtual Research Data Center in 2023 to make more data available to outside researchers.

“We want to release our model data to outside research groups so they can mine it for greater discovery about biomarkers for therapies, for example, and other things,” she said.

CMMI also will release a roadmap for multi-payer alignment and announce multi-payer models that incorporate input from stakeholders early in the model design.

Its request for information from the industry will help to formulate the model, Lukens said.

“With models, we make adjustments mid-stream, so this information is important in the process,” she said.

CMMI also will incorporate patient and caregiver perspectives in future models and publish approaches to reflect those perspectives, including those shared during regular patient and caregiver listening sessions.

Lukens also pointed to the October announcement that CMS has announced a two-year extension for the Bundled Payments for Care Improvement Advanced (BPCI Advanced) model.

BPCI Advanced was slated to end Dec. 31, 2023, and will now continue until Dec. 31, 2025.

Medicare Accountable Care Organizations not currently participating in BPCI Advanced will be able to apply to participate over the additional two-year period, with a “Request for Applications” expected in early 2023.

Innovation more than ‘a state of mind’

On the industry’s state of play, Lukens said, “innovation is not just a state of mind,” and progress is being made. Accountable Care Organizations (ACO), for example, are seeing more innovation, she said.

These groups’ residents reflect a “complex patient,” she said, citing one example where a resident was “heading for a crisis” while in a nursing home and she was sent to a hospital. There, the environment exacerbated her anxiety, and it was determined that using a catheter to provide medication would alleviate the situation, so she was sent home and avoided a long hospital stay.

The dialogue the medical teams had with the ACO helped the process, Lukens said.

In fact, Lukens emphasized the importance of information sharing, particularly with the vast amounts of data the CMS Innovation Center has.

Equally, she said it’s important to be transparent to let the public know about who is participating in programs.

In terms of building partnerships, Lukens said the CMS Innovation Center has been “very clear” about the importance the role of primary care physicians (PCP) should play in building the population health model to create a “more patient-centered way” of care at all levels, including long-stay nursing residents. Care relationships are different when they take place at the “in-person” level,” she said.

Progress and pain points

McClellan said health care organizations are facing a new and difficult practice environment. Many are stretched thin in terms of staff needs and financial support.

“Many organizations did move quickly to make changes in pandemic, taking advantage of telehealth, site of service flexibilities, and special emergency funding,” he said. “But now many of those flexibilities and the special funding are going away – at least in traditional FFS payment.”

He added that this is all happening against a backdrop of workforce shortages, burnout, and violence; a difficult financial environment for driven by the increasing practice costs from challenging supply chains, costs to meet surge preparations, and inflation; continuing challenges related to health inequities and the disproportionate impact of COVID-19 on marginalized populations.

“The unfortunate reality is that many Americans deferred needed care, including primary care and urgent services, which may have long-term impacts on population health outcomes,” McClellan said.

Nonetheless, there is more evidence than ever that accountable care reforms aligned with the goals of whole-person care can transform people’s experience with the health care system, he said.

McClellan said that the LAN, which works to advance multi-payer payment reform to enable accountable care — would like to do more work with AHCA and ACL and it just started an Accountable Care Action Collaborative.

Said McClellan, “So, you’re probably doing the math, and concluding – like all of us involved in this effort – that progress on accountable care must increase as we come out of the pandemic and face both more pressures to make progress as well as challenges in doing so.”