Value-Based Care Examined by House Ways & Means Subcommittee

June 27, 2024

BY Nicole Fallon

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The House Ways & Means Subcommittee on Health is digging into the effectiveness of value-based care and seeking ideas for how it can be improved for providers and patients.

The House Ways & Means Subcommittee on Health heard testimony at a June 26 hearing on improving value-based care for patients and providers. Much of the focus on value-based care was through the lens of primary care providers.

The hearing opened with a panel of testifiers, which included two chief medical officers, a CEO for Coastal Carolina Health Care medical practice and Dr. Robert Berenson, who is both a medical doctor and a self-described "policy wonk" now working with Urban Institute. Each testified about what works and doesn't work in value-based care for providers and patients.

Panelists echoed many issues LeadingAge has raised with the Center for Medicare and Medicaid Innovation in recent years, such as:

• Advanced investment payments are important for helping smaller providers or those with smaller margins to be able to participate and to assist in bridging the gap between changing health care delivery patterns that lower utilization/reimbursement and receipt of the "savings" generated by these changes.
• Value-based incentives should be available to providers across the continuum of care as all providers play a role in patient outcomes.
• Payments should financially reward providers to spend more time with patients to address broader factors impacting their health to effect real change in behaviors and resulting health outcomes.
• Sometimes we don't need a new model but instead smaller policy or reimbursement changes could achieve the desired goals to change care delivery and spending.

More specifically, Berenson opened his testimony by stating he is a proponent of value-based care but feels value-based payment is off track and requires rethinking. Specifically, he noted pay-for-performance has not worked to improve quality and leads to operational dysfunction.

One striking bit of testimony from Berenson was that contrary to what Medicare Advantage (MA) plan claims that they reduce hospital stays, the reality is the plans are merely reclassifying hospital inpatient stays as outpatient care. Upon closer look at the data, hospitalizations are actually higher in MA than FFS.

Other testifiers noted that current provider payments fail to reward non-procedural work such as care coordination, spending time talking to the patient about how they can affect their conditions, and taking pre-emptive measures to address growing issues. For successful ACOs, the current payment structure based on historical costs make it increasingly difficult to achieve further reductions and without change may leave these ACOs no choice but to exit the program.

The overall themes that arose throughout the hearing included:

• the unique challenges rural providers face in participating in value-based payment arrangements (e.g. low volume exclusions)
• opportunities and needed changes in accountable care organizations
• a need for transparency and some policy changes within CMMI
• flaws in current payment methodologies at both the provider level and within the ACO structure

While subcommittee members touted bills they have introduced to address some of these issues throughout the hearing, there was no clear outcome or next steps identified. It does appear from this hearing and other recent Congressional hearings that there may be attempts to restructure CMMI's role or place some additional guardrails around its activities.

The hearing can be viewed in its entirety here.