From Botany to Bundles: Tending the APM Ecosystem

Last year, I wrote a newsletter column titled Wanted: Experienced Gardner where I discussed the June 2021 Medicare Payment Advisory Commission (MedPAC) report recommending CMS streamline its Alternative Payment Model (APM) portfolio. In that report MedPAC called on CMS to move away from the “let many flowers bloom” approach to model design and focus on creating an ecosystem of models intended to work together. As the calendar turns to February, spring planting season still seems far away. Yet, experienced gardeners know this is the time to start ordering seeds and planning what will go where in their plots. In a similar fashion, while significant action on new models at CMMI still feels a long way off, the Task Force has been busy thinking about what the next crop of models should look like.

Our health care system has evolved into a monoculture with individual specialties carving out distinct niches in the health care landscape. In agriculture, monocultures appear sensible, tidy, and – at first blush – easier to manage. ?Each plant with a dedicated space, clear lines, no messy overlaps, a system designed for the convenience of the grower. Yet, monoculture ignores the beneficial relationships that naturally occur between plants. The result, an ever-growing list of inputs needed to maintain productivity – fertilizer to combat soil imbalances, pesticides, loss of biodiversity, etc. The alternative, companion planting, takes more preparation and effort from the grower. It requires a detailed understanding of the needs of each plant and how they work together. It is more time consuming and harder to automate, but the investment in grouping mutually beneficial plants together is a healthier ecosystem with improved outcomes using fewer inputs.

To date the CMS APM portfolio has largely replicated the monocultures of the underlying health care system. While CMS has made strides in encouraging team-based care, the model portfolio remains organized around primary care on one side and specialty models on the other. CMS efforts to prevent duplicate shared savings payments have resulted in overlap policies that maintain clear lines between models but prevent mutually beneficial collaborations that could improve care delivery, patient outcomes, and savings for CMS and providers. Leadership at CMS is aware of this issue and has begun reaching out to stakeholders to gather input on how to address the shortcomings of the current overlap strategy.

In January, the Task Force launched an effort to develop a companion planting guide for APMs. Specifically, we are endeavoring to develop a set of recommendations for strategies that CMS should employ to address beneficiary overlap issues and drive alignment across APMs focused on both primary care and specialists in a manner that aligns incentives for care coordination, quality improvement, and cost efficiency. Volunteers from our various work groups have agreed to participate on a strike group focused on defining opportunities for model reforms. Additionally, the Task Force has reached out to our patient, payer, provider, and purchaser members to gather their feedback on recommendations for CMS. Over the next few months, we hope release guidelines for a better APM ecosystem. Stay tuned!?