The last two years have dramatically strengthened the ACO role in providing accountable care. New CMS specialty payment models—TEAM, ASM, and the proposed CJR-X—each include specific provisions for ACO coordination and referrals, extending the ACO’s reach deep into the specialty care continuum. LEAD, the new long-term ACO model with prospective payments, has redefined the future of…
Despite ongoing improvement, stakeholders highlight need to modernize how accountable care models are evaluated The 115 accountable care organizations that participated in ACO REACH in Performance Year 2024 generated $2.5 billion in gross savings, with $988.3 million returned directly to the Centers for Medicare and Medicaid Services (CMS), for the care of 2.5 million seniors,…
CMS’ Advancing Chronic Care with Effective, Scalable Solutions model launched July 5, testing whether paying organizations for outcomes — rather than specific services — can expand access to technology-supported chronic care. Behavioral health is one of four clinical tracks, alongside musculoskeletal pain and two cardio-kidney-metabolic tracks split by disease stage, putting depression and anxiety management on equal footing with…
When CMMI released the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, it did something the Innovation Center rarely does this narrowly. It built a payment experiment around specific measured outcomes. CMMI usually builds population-based payment incentives and bundled payments, with specific components around highly prevalent chronic conditions layered in rather than made the…
For the longest time, physician practices have operated on a fee-for-service model that pays for visits, tests and procedures. We’re finally seeing a shift toward more value-based care models that base compensation on the quality of care and a patient’s longevity of health, a shift that I believe is better for all parties involved. The U.S. Centers for…
Health care leaders have long viewed fraud, waste, and abuse as compliance issues. But as more provider organizations accept financial risk through accountable care and other value-based arrangements, fraud, waste, and abuse are no longer simply compliance concerns. They are increasingly financial performance risks that can directly affect benchmark attainment, shared savings results, and care…
Sustainability has become less about cutting costs and more about redesigning how healthcare delivers value. Becker’s asked several health plan leaders how they’re thinking about long-term sustainability, and the responses point to a shared shift away from volume-driven models toward outcomes, accountability, and member-centered design. From shifting social health programs toward measurable, evidence-based interventions to redesigning the…
Download Slides CMS has doubled down on its commitment to reining in specialty costs by proposing another mandatory episode-based care model: Comprehensive Care for Joint Replacement Expanded, or “CJR-X.” Like the Transforming Episodic Payment Model (TEAM), CJR-X is focused on procedural episodes of care, but its global application and pinpoint focus will drastically impact…
In our last four articles, we have focused on payment models and infrastructure to establish how ACOs can be central to Value-Based Care, even under specialty models. Now it’s time to shift our focus back to what the payment models set out to do: improve patient health and rationalize costs. We cannot lift up patient…
Addressing Structural Challenges in the Business of Benefits Through AI Innovation Employer plans, whether self-funded under the Employee Retirement Income Security Act of 1974 (ERISA) or fully funded through a commercial plan, will likely have a proactive mindset that will lead to greater coverage modeling scenarios, plan accountability, and a focus on outcomes to successfully…
AI isn’t failing because it lacks capability. It’s failing because it isn’t consistently reaching the moments where decisions are made. Healthcare isn’t struggling to adopt AI. In fact, the industry has moved quickly from early experimentation to widespread investment in tools designed to improve clinical decision-making, reduce administrative burden, and drive financial performance. Many health…
Value-based care runs on a simple bet: an organization takes financial responsibility for a population’s health and keeps the savings if it can hold costs down. The organizations making that bet, physician-led IPAs, ACOs, Medicare Advantage groups, and the health plans they contract with, all run the same kind of back office to deliver on…