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 spending. Heart failure and low back pain are among the costliest conditions with annual Medicare spending of $10-13 billion and $6-$8 billion respectively. People with these conditions often see multiple clinicians and their care can become fragmented. This leads to challenges in care coordination across medical providers and care settings, leading to treatment delays, unnecessary procedures and hospitalizations, and higher spending without improved health outcomes.
ASM will test how different incentives, primarily performance-based payment adjustments, can transform specialist care delivery to improve chronic disease prevention, early diagnosis, and disease management.
Goals
ASM aims to improve health outcomes and lower costs for patients with heart failure or low back pain by:
- Increasing active collaboration between select specialists and primary care providers
- Improving chronic disease management and preventing development of additional disease through better risk assessment
- Reducing avoidable hospitalizations and unnecessary procedures
- Offering greater transparency in ASM participant performance
- Measuring outcomes that center on patient priorities
- Empowering select specialists by aligning performance measures with factors they are better able to control
Innovation - Payment
ASM leverages the CMS Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) framework. Like MVPs, ASM’s performance measures and activities are tailored to the provider type and condition being treated. ASM goes further by offering a more focused set of measures and activities to simplify reporting and compare performance among peers treating the same chronic condition.
For each ASM performance year, ASM will evaluate eligible ASM participants’ performance across four categories:
- Quality, a focused set of clinical measures relevant to each chronic condition and specialty type, such as controlling blood pressure of patients with heart failure or improving functional status of patients with low back pain.
- Cost, validated episode-based cost measures (EBCMs) specific to each chronic condition, with a focus on reducing avoidable and unnecessary care.
- Improvement activities, efforts to improve screening for health-related social needs and strengthen care coordination between ASM participant specialists and primary care providers.
- Improving interoperability, measures and activities that encourage the adoption and use of certified electronic health record technology (CEHRT) to support electronic communication and data sharing.
The model uses a two-sided risk arrangement, meaning that ASM participants will be subject to financial gains or losses. Based on performance relative to their peers, ASM participants will receive a positive, neutral, or negative payment adjustment on future Medicare Part B claims for covered professional services. Payment adjustments range from -9% to +9% in the first two ASM performance years, increasing to -12% to +12% by the final ASM performance year.
Innovation - Collaboration
ASM tests tools designed to improve collaboration, including Collaborative Care Arrangements in which ASM participants and primary care providers have clearly defined roles, responsibilities and expectations for data sharing, co-management of patient care and referral processes. Both ASM participants and primary care providers may contribute to screening for health-related social needs and may jointly prepare plans for patient transitions between care settings, such as an outpatient treatment facility and home.
ASM participants will be incentivized to use CEHRT to communicate and share data with collaborating medical providers. Under ASM, CMS intends to offer ASM participants access to enhanced performance data related to episode-based costs, utilization, and quality, enabling deeper insight into patients’ care patterns and needs.
