Navigating Value-Based Care for Nursing Homes: A Guide
Navigating the new value-based care frameworks introduced by the Centers for Medicare & Medicaid Services (CMS) can be complex for nursing home operators. Two models—the Long-Term Enhanced ACO Design (LEAD) and the Transforming Episode Accountability Model (TEAM)—present significant opportunities for these providers.
Brian Fuller, overseeing value-based care design at ATI Advisory, highlights the TEAM model as promising for nursing home engagement despite current limited readiness from hospitals. Fuller anticipates greater participation by 2027, when hospitals start facing financial downside risks. For now, hospitals are experiencing only upside opportunities.
Fuller predicts CMS will introduce more accountable care organization (ACO) models, possibly similar to the Program of All-Inclusive Care for the Elderly (PACE), to include dual-eligible and complex care models, which will likely intersect with nursing home operations. The aim is designing models to achieve parity between Medicare’s fee-for-service (FFS) and Advantage plans, incorporating beneficiary incentives like Part B cost sharing.
A substantial portion of Medicare FFS spending, about 70%, is unmanaged by an ACO, with nursing homes contributing nearly $18.9 billion compared to $6.1 billion under ACO management. This indicates potential cost savings for nursing homes aligning with ACOs, Fuller suggests.
Future Initiatives and ACO Development
CMS Innovation Center initiatives might focus on anchoring beneficiaries to primary care within the evolving ACO framework. The TEAM model exemplifies episode-based care, expanding care categories under value-based arrangements, including all lower extremity joint replacements.
Nursing home operators should be aware of 'shadow bundles' in ACOs that allow managing CMS-administered risk arrangements within care structures. The Medicare Shared Savings Program (MSSP) and REACH ACOs are gathering data on potential future bundled care models, encompassing various clinical episodes like cardiac and pulmonary conditions.
LEAD Model and New Alignment Strategies
The LEAD model is crucial for nursing home operators due to its direct relevance and sector interest. Although the first application period has closed, CMS plans further application rounds. New alignment strategies for integrating beneficiaries into ACOs provide flexibility, supporting expanded partnerships and provider networks.
Adjustments to MSSP alignment criteria, including reducing the minimum required lives for high-needs beneficiaries and incorporating functional frailty in assessments, increase models’ appeal and accessibility. Innovations from the REACH model, like refined financial benchmarking and advanced payments, enhance financial performance prospects for nursing home operators.
Fuller underscores these developments’ importance, noting CMS’s strategic redesigns are advancing ACO infrastructure to better support nursing home operators, ultimately shaping a more robust value-based care landscape.