News Update
Duke-Margolis Review in JAMA Cardiology: Work is needed to make accountable care a reality
In a review published in JAMA Cardiology, Duke-Margolis director Mark McClellan, senior policy advisory Steven Farmer, and former Research Associate Meghan George, along with researchers from the Brookings Institution, Columbia University/New York Presbyterian, and the American College of Cardiology, review existing and emerging payment and delivery reforms in cardiology and consider their implications for clinical practice.
They conclude that while more work is needed to refine alternative payment models (APMs), early participation will allow cardiologists to develop essential expertise during a period of relatively lower risk. These efforts will position cardiologists for success as payers increasingly turn to payment reforms to improve quality and reduce costs.
The United States has the highest per capita health expenditures in the world, but ranks last among developed nations in quality, efficiency, and equitable access to care. Public and private payers are experimenting with a range of APMs that align payments with value. However, historical participation has been limited, and many of these models require large upfront investments and impose significant administrative burdens.
Cardiologists should understand emerging models for payment reform and lead in their development to avoid unintended consequences. New models are needed to address chronic cardiovascular disease and to enhance primary care cardiology alignment.
In reviewing the landscape of payment reform models affecting cardiology, the authors note that most existing cardiology-oriented payment models are modified fee-for-service (FFS) or address procedural or episodic care.
The first category, traditional FFS, will not be viable in the long term as payments are not projected to keep pace with inflation. The second category, FFS models with links to quality, includes the Merit-Based Incentive Payment System (MIPS), which was established by the Medicare Access and CHIP Reauthorization Act of 2015. In the MIPS program, FFS payments will be adjusted based on a composite performance measure comprised of four categories (quality, resource use, advancing care information, and clinical practice improvement).
The third category comprises APMs based on a FFS architecture. Examples include bundled payments for procedures and episodes as well as Medicare shared savings Accountable Care Organizations (ACO). These models are intended to reward clinicians who offer efficient, high-quality care, and they may include opportunities for bonus payments as well as downside risk. Finally, the fourth category includes population based payment models that separate payments from specific services. These models compensate groups of clinicians on a per-member per-month basis to care for defined patient populations.
The authors argue that early APMs have faced a number of challenges. For example, poor coordination between payers establishes mixed incentives and generates administrative inefficiency. In addition, performance metrics are limited in scope, many providers question their reliability, and performance feedback often arrives too late to be actionable. Payers will need to address these limitations before APMs can achieve their full potential.
