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Since the implementation of the Affordable Care Act, a major shift has been underway in how individuals in traditional Medicare receive their services. The Centers for Medicare and Medicaid Services (CMS) has been systematically developing programs that focus on providing value-based care (VBC) to these enrollees. These programs include the Medicare Shared Savings Program (MSSP); the Bundled Payment Initiative for Care; ACO Realizing Equity, Access, and Community Health; Making Care Primary; and more. As of January 2023, 13.2 million of the 34.3 million (approximately 38 percent) traditional Medicare beneficiaries were in one of these programs. CMS has a stated goal of having 100 percent of traditional Medicare beneficiaries in these programs by 2030.
VBC programs are designed to meet the triple aim of improving the experience of care, improving the health of populations, and reducing per capita costs of health care. In some ways, these programs are similar to Medicare Advantage (MA), the managed care version of Medicare, in their focus on population health, managing chronic conditions, reducing overuse, and alignment of incentives. In fact, many MA plans employ VBC models with their providers.
There are significant differences between the CMS VBC models and MA. For example, MA plans leverage a variety of tools to manage cost that are not available to Medicare VBC models, such as utilization management, selective networks, and benefit design. Medicare VBCs, on the other hand, have a variety of advantages over MA, such as auto enrollment of beneficiaries, physician alignment, and flexibility in use of funds. And there is a substantial debate about the relative value of each model.
But one thing they have in common is the prevalence of dually eligible individuals enrolled in the respective programs. Almost 50 percent of dually eligible individuals are in an MA plan of some kind as of 2020. While there is no publicly available data regarding the percentage of dually eligible individuals in the current VBC programs, there is no reason to believe that it would be significantly different than the overall traditional Medicare population at 38 percent.
Dually eligible individuals are unique as they are in both Medicare and Medicaid. Much has been written about the needs and characteristics of these individuals that does not need to be repeated here. Similarly, it is well established that the two programs do not work in an integrated fashion to enable high-quality outcomes and to allow these participants to live the lives they deserve and want to live. Creating models that enable better integration is a stated policy goal of CMS and the Medicaid and CHIP Payment and Access Commission