1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?
Considerable effort and emphasis have gone into promoting and advancing alternative payment models/value-based payments. What is the evidence in Medicaid that savings are accrued sufficient to be shared with providers, and that these models improve outcomes or quality measure results? If insufficient data are found for Medicaid, how about for Medicare and/or the commercial space? Are there now agreed-upon minimum standards?
Does the evidence support one approach over another, e.g., shared savings vs shared risk, total cost of care versus episode-based contracts? Total capitation is often seen as the ultimate goal – does the evidence support this? Recognizing that most VBP contracting has been in the medical space, are there any early indications of the utility of APMs/VBP to support behavioral health care and improved quality or outcomes there? Our behavioral health colleagues seem eager to want to participate in APMs. At a minimum, they don’t want to be left behind.
2. Why are you struggling with this issue?
- There are numerous definitions as to what constitutes an APM, e.g., incentive only, shared savings, shared risk, full capitation, but it seems there should be a quality component.
- Studies are conflicting, often focused on hospitals, and there is uncertainty about benefits or even the potential for harms, related to both providers and patients.
- How do we justify continuing to push APMs if the evidence is insufficient?
- There is variation in healthcare providers’/practitioners’ understanding of VBP and of what it is and isn’t compared to what is happening in the C suite.
- Is there a healthy equity advantage to be tapped with APMs?
3. What do you want to see changed? How will you know that your issue is improving or has been addressed?
We want to see practices have additional revenue opportunities through APMs/VBP to fund/support care coordination and management, along with the ability to screen for, document, and code for social determinants. These extra dollars could be put toward care management staff and other efforts to improve quality programs and the patient-centeredness of care rendered.
If we are going to continue to encourage and study VBP, we would like to know we are moving the industry in the right direction. Specifically, we would hope to see improvement in quality measure results for Medicaid members or other outcomes for practices/systems participating in APMs/VBP. Are patients benefiting, even if they might be unaware they are in an attributed population? We likely need more on the consumer end regarding their awareness and understanding.
4. When do you need the evidence report?
Wed, 01/01/2025
5. What will you do with the evidence report?
If the findings for a Medicaid population are positive or leaning in that direction, this could go a long way toward bolstering states’ confidence in expanding these models and providers accepting them. States could use any findings to continue to educate the provider and consumer communities on these models and to inform policy. Information gleaned could be used by states in their VBP policy guidance or even in contracts states have with managed care plans. If this information were available in a year, it could be used to help shape policy and guidance in the following year.
(Additionally, as I am unable to elaborate on the date range above, my thoughts are, while this is a broad topic, at a high level it would be ideal would be ideal to have a report within 12-18 months.)
Optional Information About You
What is your role or perspective? clinician administrator
If you are you making a suggestion on behalf of an organization, please state the name of the organization - New York State Department of Health, on behalf of the Medicaid Medical Directors Network
May we contact you if we have questions about your nomination? Yes
