New Cms Innovation Center Strategy Holds Promise For Senior Living Value-based Care, Ma Plans

The Centers for Medicare and Medicaid Services is deploying a new agenda and strategy meant to shift some of the financial risk of certain payment plans to care providers.

In a new strategy released May 13, Abe Sutton, who is director of the Center for Medicare and Medicaid Innovation and CMS deputy administrator, outlined what the federal agency aims to do to help beneficiaries of programs like Medicare Advantage live healthier lives.

The strategy is meant to “promote evidence-based prevention, empower people to achieve their health goals [and] drive choice and competition for people,” according to Sutton. It includes a plan that could scale back centralized rate-setting and require providers to take on downside risk for all alternative payment models.

Larry Gumina, CEO of Westerville, Ohio-based Ohio Living, believes organizations such as Perennial Advantage help reach these goals by better caring for older adults with MA and special needs plans, and he thinks the new strategy puts senior living operators in a prime position to prove their value to the wider health care system.

“We have four years under our belt taking risk for those who are on our campus communities,” Gumina told Senior Housing News. “What CMMI is trying to do now is saying, let’s expand that value proposition and take it off campus, create choice and lean on evidence-based outcomes that providers have generated, and bring that into the general community.”

He added: “I think it aligns with provider-owned Medicare Advantage plans who’ve been doing this for several years.”

The strategy shows the current administration is “full steam ahead” on MA, according to Fred Bentley, managing director of ATI Advisory. He anticipates physician groups will view the announcement as a “shot in the arm” for their business and that they will seek out partners like senior living providers to achieve their goals.

Inside the new strategic vision

According to CMS, the new strategic plan is meant to help give people “evidence-based programs, information and choices that empower them to attain the care they need in their communities.”  That could include care in virtual settings, offices or provided in homes – or senior living, which qualifies as someone’s home.

The Innovation Center plans to continue to “evolve and design” new original Medicare models “by leveraging payment and regulatory flexibilities, such as waivers, benefit enhancements and benefit enhancement incentives.” As it does so, it will “partner with and learn from advancements in the private sector to drive transformation across the health system.”

Specifically, CMS seeks to prevent and detect diseases before they require costly treatments, or better manage conditions when they are chronic. The agency “could grant providers access to new waivers that give flexibility to deliver and incentivize preventive care” as it does so.

“For instance, we will explore waivers for accountable care entities that assume global risk to provide durable medical equipment (DME) that may bypass National Coverage Determinations if they support transition to or remaining in the home,” Sutton wrote. “Other examples are reduced cost-sharing for high-value or preventive services and payments to caregivers to better support those experiencing cognitive or functional decline.”

CMS is with its new strategy exploring mechanisms for supporting patient-centered payments “within Medicare Advantage and within ACOs and other longitudinal entities,” such as by “incorporating plan adoption of advanced payment into quality incentives or requiring a minimum percentage of provider payments be risk-based.”

CMS seeks to increase the affordability of care through mechanisms that “could include waivers that support predictable cost-sharing for certain services, drugs, or devices that improve outcomes and reduce costs as well as value-based drug and insurance designs.”

“This could also include structural reform to drug pricing that supports innovation and access,” Sutton continued.

Increasing provider participation in value-based care is another goal of the new strategic vision.

According to CMS, “models may expand the use of advanced shared savings and prospective payments to support independent provider practice participation in models.

“This could include collecting losses over longer time periods for independent providers, enabling upfront investment in patient care with advances based on collateralization methods the Innovation Center designates,” Sutton wrote. “New models or tracks within models will spur competition by stimulating and supporting a wider variety of participating providers and practices, such as those in rural communities as well as those who focus on complex care and specialty populations.”

With future models, CMS aims to “expand the use of shared savings and prospective payments to support independent provider practice participation in models, reinvest hospital capacity in outpatient and community-based care by changing certificate-of-need requirements [and] standardize design features, such as quality measures, to reduce administrative burden.”

During a webinar Tuesday, Sutton did not provide an exact date on when providers could expect to hear specifics about modifications to existing models or the creation of new models.

“I’m going to have to ask you to stay tuned on that one,” Sutton said on the webinar. “I look forward to sharing more information about the modifications we are making to existing models to align them to our strategy and to our statutory mandate. We are going to make several announcements over the coming months around new model concepts and the updates to existing models.”

‘Take it to a new paradigm’

Senior living operators have in the last half-decade built new models with which to keep residents well in their current care settings. With its new strategy, CMS is “wrapping their arms around evidence-based providers” that do just that, according to Gumina.

Ohio Living is one of the co-owners of Perennial Advantage, an arm of the Perennial Consortium.The organization takes risk by offering insurance for community members under its MA plan offerings.

With this new intention, Gumina said it could help the other members of the plan “take it to a new paradigm” due to how well he believes that operators can advance the outcomes CMS laid out. One big advantage for operators is that many insurance beneficiaries already live in their communities as a sort of captive audience.

“Let’s get to know those in our primary secondary market who live in the community, but need a provider to have their back,” he said. “That, to me, sets us apart from the Humanas and United Healthcares of the world. We have boots on the ground … unlike the typical Medicare Advantage companies who don’t have provider experience.”

A side benefit to this announcement is the potential shot in the arm for operators that utilize Accountable Care Organizations (ACOs), according to Bentley. The new strategy from CMS is another indicator the government is going to further support this model of care, he said.

“This tells us that there is broad support for those models and that we can continue to invest and continue to try and grow and try and manage more senior living residents,” he said.

Most senior living operators are not health care providers and working to advance care outcomes may not be second nature, according to Bentley. Even so, the opportunity is one that he thinks the industry has within its reach.

“If you get involved in these in some way, either you launch your own ACO with a physician group, or you just become a partner with them, or you become a partner to one of these Medicare Advantage plans … CMS sees value in this,” Bentley said. “They want providers and organizations taking on more financial accountability to deliver high quality care.”

Looking ahead, Bentley fully anticipates more physician groups, primary care doctors and insurance groups to begin approaching senior living operators to play a role as the central player in accountable care organizations.

“We’re trying to work with clients to get ahead of that so that they’re not like, doing kind of one-off deals or kind of scrambling,” he said. “But I do think it’s still going to be the kind of specialized Medicare Advantage plans or specialized physician groups that are really driving the change in the industry and getting more operators engaged.”

Morgan Gonzales contributed reporting and writing to this story.

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