Under ASM, specialists who frequently treat people with Original Medicare for low back pain or heart failure in the outpatient setting within a selected geographic areas will be financially responsible for the outcomes of their care and incentivized to better prevent and manage these conditions.
ASM will promote greater coordination between specialists and primary care providers, including those in accountable care organizations (ACOs). ASM will also prioritize transparency about provider performance in the areas of quality, care improvement, cost, and interoperability.
Background
More than two-thirds of people with Original Medicare live with at least one chronic condition, and their care accounts for most Original Medicare costs. Heart failure and low back pain are among the costliest conditions to Original Medicare, with annual spending of $10-13 billion and $6-$8 billion on each, respectively. People with these chronic conditions often experience fragmented care that can impede their ability to manage their health, leading to “low-value” care expenditures. Low-value care includes avoidable hospitalization and unnecessary procedures and can increase spending without resulting in long-term benefits or improved health outcomes.
ASM will focus on interventions that are low cost with high patient benefits. It will test how different incentives, primarily payment adjustments, could transform specialist care delivery to improve chronic disease prevention, early diagnosis, and disease management.
Goals
- Increase active collaboration between specialists and primary care providers to support better outcomes for patients at risk for and living with heart disease or low back pain
- Improve management of chronic disease and prevent development of additional disease through better risk assessment
- Reduce avoidable hospitalizations and unnecessary procedures that provide little benefit or could lead to harm
- Offer greater transparency in performance among participants and their peers
- Measure outcomes that center on the patient’s priorities
- Empower participating specialists by aligning performance measures with factors they are better able to control
Innovation - Payment
ASM will leverage the CMS Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) framework to target heart failure and low back pain.
Under ASM, participants’ performance will be assessed across four categories:
- Quality, for instance controlling the blood pressure of patients with heart failure or improving functional status for patients with low back pain
- Cost, especially from reductions in avoidable, unnecessary care
- Improvement activities focusing on clinical care processes and patient engagement and ensuring that all patients are screened for health-related social needs
- Improving interoperability by encouraging the adoption of technology, including certified electronic health record technology (CEHRT), that allows specialists to communicate and share data electronically
Like MVPs, these performance measures will be specific to the type of provider and the treatment of a specific condition. However, ASM goes a step beyond MVPs in offering an even more focused set of performance measures to simplify reporting for providers. ASM's performance measures also enable physicians – and CMS – to see how they compare against other physicians of the same specialty in the same geographic region. Such transparency should drive competition among providers, which will ultimately benefit patients.
The model will use a two-sided risk arrangement, meaning that a participant will be subject to financial gains or losses. Based on performance relative to their peers, a participant will receive a higher rate (positive payment adjustment), the standard rate (neutral payment adjustment), or a lower rate (negative payment adjustment) on their future Medicare Part B claims for covered services.
Innovation - Collaboration
ASM will test tools designed to improve collaboration, such as a Collaborative Care Arrangement in which each provider will have clearly defined roles, responsibilities and expectations for data sharing, co-management of patient care and referral processes with primary care providers. Both specialists and primary care providers will contribute to screening for health-related social needs, and they will jointly prepare plans for patient transitions between care settings, such as an outpatient treatment facility and home.
Technology will play a major role in aiding ASM participants to transform their care delivery. Participating specialists will be incentivized to use CEHRT so they can efficiently communicate and share data with collaborating providers.
Additionally, ASM intends to offer participants the opportunity to request enhanced performance data related to episode-based costs, utilization, and quality, enabling physicians to gain deeper insight into their patient population’s care patterns and care needs.
