MGMA outlines path and pitfalls in CMS 2030 value-based care push
As the Centers for Medicare and Medicaid Services (CMS) continues to promote a sweeping transition to value-based care by the end of the decade, leaders at the Medical Group Management Association (MGMA) say the goal remains aspirational. The group says conversion from fee-for-service models to value-based models are fraught with challenges tied to cost savings, program design and physician participation.
Health Exec spoke with Anders Gilberg, MGMA’s senior vice president of government affairs, about this transition in payments in the video interview above. He said federal officials have long set ambitious timelines for shifting away from fee-for-service reimbursement, but historically have struggled to meet them.
“They always throw out these big targets and I've been hearing these targets for a number of years. We actually hit the date, but rarely meet the target,” Gilberg said.
CMS innovation center tests new payment models but with limited success
Much of CMS’ current strategy is being driven through the Center for Medicare and Medicaid Innovation (CMMI), which is testing and expanding alternative payment models (APMs). Since CMMI was created more than a decade ago, it has tested nearly 40 APMs, of which only two turned out to be successful and were permanently adopted. He said a Government Accounting Office (GAO) report also cited some of these models actually cost CMS more money. Gilberg said that is not an impressive track record and leads many in healthcare to doubt CMS will meet its 2030 goal of moving completely to value-based payments.
“The GAO took a look at the effectiveness of the CMMI in their programs, and it actually was able to determine that instead of saving money over the 10-year period that they looked at, they increased spending as a result of their programs,” he said.
He added that while certain initiatives—such as the Medicare Shared Savings Program for ACOs—have shown promise, they remain exceptions.
“It remains to be seen the effectiveness of CMMI,” Gilberg said. “But the history hasn't been that successful, and many APMs have come and gone.”
A forthcoming accountable care organization (ACO) initiative known as the Long-term Enhanced ACO Design (LEAD) model is one area currently gaining traction among medical groups, he explained.
“They are expanding some aspects of an existing ACO model with the LEAD model. Some of our practices are interested in that and I think that'll come online early next year,” he said.
However, he said CMMI is also looking at initiatives that MGMA does not associate with value-based care, including the WISER model, which wants to introduce prior authorization into traditional Medicare.
“That's not really what we think about in value-based care,” Gilberg said. “Yes, it's aimed at addressing some cost issues, but value-based care is supposed to increase quality at the same time and hopefully reduce costs.”
Technology and non-physician players enter the payment system
Another emerging CMS priority is expanding the role of technology companies in care delivery and offering them reimbursement. Under a newer Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model, non-physician entities may be able to bill Medicare directly for certain services in caring for chronic disease patients.
“For the first time, technology companies might be able to bill Medicare directly for the administration of certain technology solutions,” Gilberg explained.
But he added that the early enthusiasm from industry may now be waning after they saw the very low reimbursements CMS was offering.
“The actual payments were released and they were minuscule, so that bubble might have popped a little bit,” Gilberg said.
Concerns over mandatory CMS payment models
While MGMA supports voluntary participation in value-based care, Gilberg raised concerns about the increasing use of mandatory payment models. These are mostly targeting high-cost care in some regions. The most recent effort is the new Ambulatory Specialty Model (ASM) for heart failure in cardiology and lower back pain in orthopedics that starts on Jan. 1, 2027. CMS recently posted a list of thousands of physicians who are required to participate in the ASM. Gilberg criticized what he described as top-down experimentation using these models where they divide regions into test and control groups to see how well a new model works to try and improve care or lower costs.
“We're still a big advocate for opportunities for practices to engage in value-based care,” he said. “The thing we oppose is different situations where medical practices and doctors are thrown into these mandatory models.”
Cost containment dominates current strategy
Overall, Gilberg said the Trump administration’s approach to value-based care has been heavily focused on reducing spending, sometimes at the expense of broader quality goals. While CMS initiatives have traditionally looked at how to improve care and reduce costs, the current administration's policies have shifted to mainly cutting costs.
“I would say the administration so far has been more focused on cost containment, more focused on the use of technology for cost containment, and cost containment has been really the name of the game,” he said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]