1、November 2022Looking ahead to the next decade of accountability for care deliveryMcKinsey&CompanyMcKinsey&Company is a global management-consulting firm deeply committed to helping institutions in the private,public,and social sectors achieve lasting success.For more than 90 years,our primar

2、y objective has been to serve as our clients most trusted external adviser.With consultants in more than 100 cities and in over 60 markets across industries and functions,we bring unparalleled expertise to clients all over the world.We work closely with teams at all levels of an organization to shap

3、e winning strategies,mobilize for change,build capabilities,and drive successful execution.Cover image:FS Productions/Getty Images Copyright 2022 McKinsey&Company.All rights reserved.Contents3Objective 1:Grow and improve accountable care 13Objective 2:Advance health equity15Objective 3:Support c

4、are innovations16Objective 4:Improve access by addressing affordability 19Objective 5:Promote partnerships to achieve care transformation2122ConclusionEndnotesLooking ahead to the next decade of accountability for care delivery3Authors note:Since the Center for Medicare&Medicaid Innovation(CMMI)

5、released its ten-year strategy in October 2021,the agency has taken many actions to reach its objectives,including easing participation requirements in the redesigned ACO REACH(Accountable Care Organization Realizing Equity,Access,and Community Health)model to facilitate accelerated adoption,integra

6、ting health equity tools and measurement in accountable care organization(ACO)models,and continuing multipayer alignment in its newest oncology model.Innovation in healthcare is accelerating.Seismic changes include the adoption of virtual-health modalities spurred by the COVID-19 pandemic,disruption

7、 in the payer sector by tech-based upstarts,and the expansion of care settings outside the hospital.In this environment,the Center for Medicare&Medicaid Innovation(CMMI)published in October 2021 its innovation strategy for the next decade.The strategy contains valuable indicators of new federal-

8、government priorities for stakeholders across the healthcare landscapeones that are already being implemented.CMMI was established in the Affordable Care Act to“test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnis

9、hed to individuals”across government healthcare programs.1 In the coming decade,five strategic objectives will govern CMMIs pursuits as it looks to shape and support innovation2:1.Grow and improve accountable care.2.Advance health equity.3.Support care innovations.4.Improve access by addressing affo

10、rdability.5.Promote partnerships to achieve care transformation.If CMMI realizes its vision,stakeholders may expect 30 million to 35 million additional Medicare lives covered in accountable care relationships by 2030,increased flexibility to broaden access and reduce consumer costs,greater support t

11、o reshape care delivery models,increased accountability for health equity,and increased coordination between public and private entities to deliver these changes to the system.Some of the success of these aspirations will depend upon the priorities of CMMI leadership,which may vary.3At the same time

12、,this reports analysis suggests that if CMMI does successfully achieve its objectives,it may not meaningfully change the cost trajectory in Medicare,4 and system savings may still be insufficient to mitigate projected depletion of the Medicare Hospital Insurance Trust Fund,for example.5 However,the

13、Centers for Medicare&Medicaid Services(CMS)maintains its commitment to accountable care models as a viable path to improving cost efficiency in the long term while advancing other objectives,such as improving patient centeredness and health equity,in the interim.One year ago,the Center for Medic

14、are&Medicaid Innovation outlined five strategic objectives that signaled its priorities for the decade ahead.We examine the objectives and progress to date.Zahy Abou-Atme Stephanie CarltonIsaac Swaiman 2Looking ahead to the next decade of accountability for care deliveryThis report is an in-dept

15、h examination of CMMIs five strategic objectives.Understanding the implications of CMMI achieving these renewed objectives at scale will help leaders steer their organizations along these innovative tides.Objective 1:Grow and improve accountable careCMMIs first objective is to transition virtually a

16、ll Medicare and Medicaid beneficiaries into accountable care relationships by 2030.Accountability in care delivery models can take many forms.We understand CMMIs aspiration to ensure beneficiaries are in a long-term relationship with care providers accountable for health outcomes and financial risk(

17、such as a risk-bearing accountable care organization ACO6).Similarly,CMMI defines such a relationship for Medicaid beneficiaries as“arrangements that drive accountability for quality,outcomes,and cost.”In addition,Medicare Fee-For-Service(FFS)has an array of performance programs that evaluate both o

18、rganizations(for example,home health,hospitals,or hospice)and clinicians(for example,primary-care physicians and nephrologists).The Quality Payment Program,under which the Merit-based Incentive Payment System(MIPS)rewards clinicians for various quality parameters,is one of the broadest performance i

19、ncentive programs in FFS.Given that CMMIs articulation of this objective primarily discusses the Medicare population,this report does the same.Accountable care relationships by the numbersOf the 57.7 million Medicare beneficiaries enrolled in Parts A and B in 2021,7 CMMI estimates that 13million(23

20、percent)8 were enrolled in some form of ACO model,including both one-sided arrangements(in which participants share only generated savings)and two-sided arrangements(in which participants share generated savings and losses).Such ACO models include the permanent Medicare Shared Savings Program(MSSP)a

21、nd broader CMMI demonstration models.9 Another 27.2million(47percent)were enrolled in Medicare Advantage(MA)or similar,privately administered plans.(MA plans are held accountable for quality and financial risk,though do not always involve a long-term relationship with an accountable provider.For the

22、 purposes of this analysis,we will focus on the“gap”to accountable care for beneficiaries not enrolled in MA.10)The remaining 17.5 million beneficiaries(30percent)fall into the current accountable care“gap.”If current ACO and MA penetration were to hold as Medicare grows to cover 77.4 million projec

23、ted beneficiaries by 2030,11 this gap would encompass 23.5 million beneficiaries.However,the market penetration of MA has grown rapidly over the past decade,so the gap for those remaining in Medicare FFS could be considerably smaller.For instance,the Medicare Trustees project that 52 percent of bene

24、ficiaries(40.5 million)will receive coverage via MA by 2030.12If we use the trustees projections,then 4.4 million additional Medicare FFS beneficiaries would need Understanding the implications of CMMI achieving these renewed objectives at scale will help leaders steer their organizations along thes

25、e innovative tides.3Looking ahead to the next decade of accountability for care deliveryto be enrolled in one-or two-sided accountable care models for current ACO penetration to hold through 2030,and an additional 19.4 million beneficiaries(a total increase of 23.8 million beneficiaries)would need t

26、o be enrolled in such models to meet CMMIs goal of 100 percent(Exhibit1).Scaling accountable care penetrationEnrolling 23.8 million additional FFS beneficiaries in accountable care necessitates nearly doubling current ACO enrollment by 2030.Notably,if many early adopters of accountable care have alr

27、eady begun participating in MSSP and CMMI ACOs,an expansion to the next wave of participants would likely require substantial resources and prioritization.ResourcesPrivate-sector stakeholders may accelerate CMMIs goals by deploying capital and market experience to help scale accountable care models.

28、This could include funding capability building for providers newer to value-based care,educating beneficiaries on the benefits of receiving care in an ACO,or directly participating in ACO models at scale.The extent to which private entities can contribute to ACO growth could be determined by how att

29、ractive CMMI makes it for innovators and other nontraditional organizations to participate(such as through offering ownership requirements or infrastructure payments).PrioritizationCMMI and supporting private stakeholders may look to pursue accountable care arrangements in geographic areas with high

30、er value-generating penetration and lower current accountable care penetration.Exhibit 1Web Exhibit of The Center for Medicare&Medicaid Innovation aims to shift 100 percent of Medicare benefciaries into an accountable care relationship by 2030.McKinsey&CompanyMedicare enrollment by program,2

31、02130,millionsNote:Figures may not sum,because of rounding.1Fee-For-Service.2Counts benefciaries in one-sided risk Medicare Shared Savings Program(MSSP)tracks(Basic A,Basic B,Track 1).3Counts benefciaries in two-sided risk MSSP tracks(Basic CE,1+,2,3),Oncology Care Model,Kidney Care Choices(includin

32、g one-sided Graduated track given absence of track-specifc enrollment data),Kidney Care First,Primary Care First,and Global and Professional Direct Contracting Model.4Center for Medicare&Medicaid Innovation.Source:2021 annual report of the Boards of Trustees of the federal Hospital Insurance and

33、 federal Supplementary Medical Insurance trust funds,Boards of Trustees,2021;Innovation center strategy refresh,Centers for Medicare&Medicaid Services(CMS),October 2021;“Medicare benefciary demographics,”Medicare Payment Advisory Commission,July 2021Medicare FFS1:No accountable care relationship

34、Medicare FFS:One-sided accountable care2Medicare FFS:Two-sided accountable care3Medicare FFS:One-or two-sided accountable careMedicare Advantage2021(per CMMI4)2030(goal)587737412776184Looking ahead to the next decade of accountability for care delivery1.Higher value-generating potential:This include

35、s areas with opportunities to reduce excess healthcare cost and improve quality,defined in this report by factors such as projected population growth,regional disease burden,level of avoidable inpatient spending,and use of alternative care settings(for example,an outpatient surgery center).132.Lower

36、 accountable care penetration:This includes areas with opportunities to cover lives not currently enrolled in accountable care relationships,defined in this report as a combined proportion of Medicare beneficiaries currently enrolled in MA or MSSP.14By calculating a composite score for each of these

37、 two criteria,all 913 US core-based statistical areas(CBSAs)15 were segmented into four market archetypes based on their viability for accountable care(Exhibit 2).The analysis suggests that 59 percent of CBSAs with high value-generating opportunity already have high accountable care penetration,impl

38、ying that risk-bearing entities have often recognized and acted on this opportunity.However,23 percent of all CBSAs have high value-generating opportunity and low accountable care penetration,16 for which new accountable care entrants would have a first-mover advantage(see sidebar“A breakdown of mar

39、ket opportunities”).Exhibit 2Web Exhibit of More than half of core-based statistical areas(CBSAs)have become high value-generating opportunities.McKinsey&CompanyAccountable care organization(ACO)market viability,1 by CBSA1ACO market viability considers market ACO penetration and market value-gen

40、erating opportunity.Markets with a frst-mover advantage are those in the bottom 50%in penetration and top 50%in opportunity.Established-viability markets are those in the top 50%in both penetration and opportunity.All other markets have below-average value-generating potential and are unlikely to be

41、 primary expansion targets for the Center for Medicare&Medicaid Innovation(CMMI)or private stakeholders.Value-generatingopportunityLowHighFirst-mover advantage23%of CBSAsEstablished viability33%of CBSAsLimited viability27%of CBSAsMarket saturation17%of CBSAsACO penetrationLowHigh5Looking ahead t

42、o the next decade of accountability for care deliveryA breakdown of market opportunitiesWithin these first-mover-advantage markets,83 percent of core-based statistical areas(CBSAs)are in the South or Midwest and have an average population of less than 75,000 people.Established-viability markets are

43、also concentrated in the South and Midwest but have an average population of 171,000;private entities may see less of an addressable market in geographies with smaller populations,which could explain the current differences in penetration.The West may hold the least short-term potential for accounta

44、ble care;only 23percent of markets have above-average value-generating opportunity.While the Northeast has considerable value-generating opportunity,accountable care penetration there is already quite high,with 76 percent of high-opportunity markets indicating above-average penetration(exhibit).Acco

45、rdingly,there appears to be the highest opportunity for increased uptake of accountable care in the South and Midwest.Lower-population geographies in these regions could be especially fertile ground for publicprivate partnerships to pursue accountable care,given that more rural areas often require d

46、eeper care-model innovation and that smaller market sizes may be less attractive to private entities alone.ExhibitWeb Exhibit of Core-based statistical areas(CBSAs)in the South and Midwest present the best opportunities for accountable care markets.McKinsey&CompanyNote:Accountable care organizat

47、ion(ACO)market viability considers market ACO penetration and market value-generating opportunity.Markets with a frst-mover advantage are those in the bottom 50%in penetration and top 50%in opportunity.Established-viability markets are those in the top 50%in both penetration and opportunity.All othe

48、r markets have below-average value-generating potential and are unlikely to be primary expansion targets for the Center for Medicare&Medicaid Innovation(CMMI)or private stakeholders.All CBSAsFirst-mover advantageEstablished viabilityOther CBSA6Looking ahead to the next decade of accountability f

49、or care deliveryPotential impact on Medicare financesHistorically,discussions about Medicare ACO models have focused largely on targeted and realized savings for the federal government.For instance,in 2022,CMS reported that MSSP saved$1.6 billion in federal spending in 2021.17(MSSP is not a CMMI mod

50、el,but it is a useful reference for estimating savings potential since it is the broadest accountable care program in Medicare.)This estimate of savings has not been validated by a government-funded third-party evaluation.Moreover,adding more high-cost providers to the program could alter savings ou

51、tcomes.We defined three scenarios to assess potential Medicare savings in 2030 that would result from a 100 percent shift to accountable care.For each scenario,we applied distinct,empirically informed ACO savings rates(based on historical model performance)and risk-level uptake rates(that is,full,tw

52、o-sided,and one-sided).(For a breakdown of these levels,see sidebar“Explanation of risk-sharing levels.”)Based on experience with existing Medicare accountable care programs,scaling accountable care to all non-MA beneficiaries by 2030 may have only a limited impact on annual government expenditures.

53、Still,we recognize future program designs could result in higher savings rates.We estimate that a shift to 100 percent accountable-care enrollment could drive a range of Medicare spending changes in 2030,18 from a 0.04percent increase($0.6 billion)to a 2.45 percent decrease($40.5 billion)in annual e

54、xpenditures compared to projected spend in 2030(Exhibit 3).The“low performance”scenario draws on historical net performance from MSSP,Next Generation(Next Gen)ACO,and Comprehensive Primary Care Plus(CPC+);the last two were a net cost to CMS.The“middle performance”scenario reflects the latest net per

55、formance in MSSP alone as of 2021.The“high Explanation of risk-sharing levelsParticipants in accountable care arrangements often make selections between and within demonstration models based on the level of risk they bear for their cost performance.For example,the Medicare Shared Savings Program(MSS

56、P)offers tracks with one-sided and two-sided risk,and ACO REACH(Accountable Care Organization Realizing Equity,Access,and Community Health)offers a choice between partial two-sided risk and full risk.An explanation of these different models are as follows:One-sided risk arrangements allow participan

57、ts to share in any savings generated against their cost benchmarks while insulating them from expenditures above this benchmark.These models often have caps on the extent to which participants can share in savings.Two-sided risk arrangements allow participants to share in any savings generated again

58、st their cost benchmarks while also holding them accountable for any expenditures above this benchmark.These models often have caps on the gains and losses that participants can accrue,with caps on gains often higher than those in one-sided models to compensate for greater accepted risk.Full risk ar

59、rangements are a special case of two-sided risk models in which there are no caps on either gains or losses accrued;participants earn the full amount they save while paying for the full amount they spend above benchmark.It is worth noting that,in most arrangements,the ability to earn savings is subj

60、ect to minimum-quality performance(for example,patient experience or the avoidance of high-acuity events).Smaller and less-experienced participants often prefer one-sided arrangements because their capabilities to bear risk may not be mature enough to confidently avoid heavy losses,and they are will

61、ing to accept lower potential upside in return.Participants with experience bearing risk and tested capabilities are more likely to select two-sided(or full)risk arrangements given the higher potential upside and greater confidence in the management of their medical costs.7Looking ahead to the next

62、decade of accountability for care deliveryperformance”scenario uses the top-fifth percentile MSSP gross savings rate,which is similar to the efficiency that MA plans incorporate into their Parts A and B bids.19These estimates use the most recent data available based on historical performance of ACOs

63、,but innovations and challenges in the coming decade could materially change total maximum ACO savings.Exhibit 3Web Exhibit of An increase in Medicare accountable care organization(ACO)enrollment may not lead to meaningful government savings.McKinsey&CompanyProjected annual government health car

64、e savings in 2030,1 by scenario,$billionsNote:Assumes 47.6%of benefciaries are enrolled in Medicare Fee-For-Service(FFS)and in an accountable care organization(ACO)(based on 2022 Medicare Trustees Report estimate of 52%for 2030 Medicare Advantage MA enrollment).1Incorporates shared savings payments

65、to ACOs and providers,Advanced Alternative Payment Model(AAPM)bonus payments to providers.Does not include cost of running Center for Medicare&Medicaid Innovation(CMMI)($1 billion per year).2ACO savings rates set to average most recent net performance of MSSP,Next Gen,and CPC+ACOs,across risk ty

66、pes,improving at same rate as overall Medicare spending growth.Risk model uptake refects current split across Medicare ACO enrollees between 1-sided(55%)and 2-sided(45%)models,assuming some move toward full capitation.This assumes that many current ACO-participating providers will move toward 2-side

67、d risk but that most new entrants will prefer 1-sided risk.3Medicare Shared Savings Program,Next Generation,and Comprehensive Primary Care Plus.4ACO savings rates set to average net performance of 2020 MSSP ACOs,across risk types,scaled to 125%of current savings to refect improvement over time and f

68、rom multipayer participation.Risk model uptake refects all current Medicare ACO enrollees who move into at least two-sided risk arrangements(while some move toward full capitation),with benefciaries newly in risk-bearing models adopting the current 55%one-sided vs 45%two-sided risk breakdown.5ACO sa

69、vings rates set to 95th percentile net performance of 2021 MSSP ACOs,across risk types,scaled to 125%of current savings to refect improvement over time and from multipayer participation.Risk model uptake assumes that CMMI transitions fully to 2-sided and capitated models and that the current breakdo

70、wn of Global and Professional Direct Contracting(GPDC)model Direct Contracting Entities(DCEs)between two-sided risk(70%)and full capitation(30%)is the best that CMMI can do to push for increased risk taking,given selection biases in DCE uptake.Source:2020 annual report of the Boards of Trustees of t

71、he federal Hospital Insurance and federal Supplementary Medical Insurance trust funds,Boards of Trustees,2020;2022 annual report of the Boards of Trustees of the federal Hospital Insurance and federal Supplementary Medical Insurance trust funds,Boards of Trustees,2022;Dan Grunebaum,“Medicare Advanta

72、ge national penetration rates,”MedicareGuide,January 4,2022;J.Michael McWilliams and Alice Chen,“Understanding the latest ACO savings:Curb your enthusiasm and sharpen your pencilspart 1,”Brookings,November 12,2020;Jeannie Fuglesten Biniek,Juliette Cubanski,and Tricia Neuman,“Higher and faster growin

73、g spending per Medicare Advantage enrollee adds to Medicares solvency and afordability challenges,”KFF,August 17,2021;Juliette Cubanski et al.,“How much do Medicare benefciaries spend out of pocket on health care?,”KFF,November 4,2019;Innovation center strategy refresh,Centers for Medicare&Medic

74、aid Services(CMS),October 2021;“Medicare benefciary demographics”and“The Medicare Advantage program:Status report,”Medicare Payment Advisory Commission,July 2021;Michael Zhu et al.,“The Medicare Shared Savings Program in 2020:Positive movement(and uncertainty)during a pandemic,”Health Afairs,October

75、 14,2021;“National health spending in 2020 increases due to impact of COVID-19 pandemic,”CMS,December 15,2021;Performance Year Financial and Quality Results,CMS,January 2020;McKinsey analysisLow performance2(MSSP,Next Gen,and CPC+)3Middle performance4(MSSP)High performance5(95th percentile MSSP)$29

76、percapita lost$728 percapita saved$1,920 percapita savedSavings rate,%Penetration,%55.000.431sided35.000.552-sided10.000.55Fullcapitation3.1636.001sided6.0549.002-sided6.0515.00FullcapitationN/A0.001sided9.4670.002-sided13.0430.00Fullcapitation40.515.30.68Looking ahead to the next decade of accounta

77、bility for care delivery(MSSP savings estimates have not been validated by a third-party evaluation,and adding more high-cost providers to the program could alter savings outcomes.This estimate also reflects the high end of potential savings because it is based on the most recent performance.At the

78、end of 2021,the average MSSP had been in the program for at least four years;the estimates account for improvements those participants made over time.These scenarios do not vary performance of participants by year or cohort where older cohorts could have higher savings,while newer cohorts may begin

79、with lower savings and improve with greater experience.)Policy decisions,the market,and the operational efficiency of participants could influence the savings that ACOs achieve.For example,savings rates could be higher if more participants join ACO REACH(Accountable Care Organization Realizing Equit

80、y,Access,and Community Health)or if the share of physician-led ACOs,which have historically had higher savings rates,increases.All scenarios account for Advanced Alternative Payment Model(AAPM)bonuses but not for the$1 billion annual cost of CMMI(see sidebar“ACO scenario definitions”).Savings projec

81、tions are purely for beneficiaries covered by Medicare FFS in 2030 and represent savings generated by all existing and potential future ACOs.To contextualize these projections,none of the savings estimates would be sufficient to prevent the projected depletion of the Medicare Hospital Insurance Trus

82、t Fund.Even in the highly ambitious high-performance scenario,savings would represent approximately 25 percent of the funds projected annual deficit in 2030.ACO scenario definitionsAll scenarios assume that the uptake for Medicare accountable care organizations(ACOs)is 48.0 percent(versus 49.2percen

83、t uptake in ACO REACH Accountable Care Organization Realizing Equity,Access,and Community Health per the 2021 Medicare Trustees Report):Low-performance scenario:ACO savings rates are set to average the most recent net performance of Medicare Shared Saving Program(MSSP),Next Generation,and Comprehens

84、ive Care Plus(CPC+)ACOs,across risk types,improving at same rate as overall Medicare spending growth.Risk model uptake reflects the current split across Medicare ACO enrollees between one-sided(55 percent)versus two-sided(45percent)models,assuming some move toward full capitation.This assumes that m

85、any current ACO-participating providers will move toward two-sided risk,but the majority of new entrants will prefer one-sided risk.Medium-performance scenario:ACO savings rates are set to average the net performance of 2021 MSSP ACOs,across risk types,scaled to 125 percent of current savings to ref

86、lect improvement over time and improvement from multipayer participation.Risk model uptake reflects a situation in which all current Medicare ACO enrollees move into at least two-sided risk arrangements(with some moving toward full capitation),with beneficiaries newly in risk-bearing models adopting

87、 the current 55 percent one-sided versus 45 percent two-sided risk breakdown.High-performance scenario:ACO savings rates are set to the 75th percentile of the net performance of 2021 MSSP ACOs,across risk types,scaled to 125 percent of current savings to reflect improvement over time and improvement

88、 from multipayer participation.Risk model uptake assumes that the Center for Medicare&Medicaid Innovation(CMMI)transitions fully to two-sided and capitated models and that the current breakdown of global and professional direct contracting(GPDC)direct-contract entities(DCEs)between two-sided ris

89、k(70 percent)and full capitation(30 percent)is the best that CMMI can do to push for increased risk taking,given selection biases in DCE uptake.9Looking ahead to the next decade of accountability for care deliveryCMMI also considers MA plans in its definition of accountable care relationships,althou

90、gh Medicare Advantage Organizations(MAOs)are not required to take on risk.The top-fifth percentile MSSP gross savings rate of 10.2 percent is close to the efficiency reflected in the average bids of MA plans,which were 12 percent less than FFS spending on average in 2021(though net payments are diff

91、erent than FFS spending due to policy choices).Given that many plans already have at-risk contracts with providers,market incentives to deliver high-value care may also resemble those for participants in ACO arrangements.As such,the extent to which meaningful savings could be realized by the federal

92、 government via 100percent accountable care is based on enrollment of FFS members in high-performing ACOs and net payment levels to MA plans.CMMI aims to identify the best practices from high-performing ACOs and incorporate them into MSSP.20Improvements in care qualityIncreasing accountable care enr

93、ollment holds the potential to improve quality and outcomes compared to Medicare FFS.Some ACO models,including MSSP and Pioneer ACO,have driven improvements across more than 80 percent of quality measures,21 but others,including Next Gen ACO,have not demonstrated the same results.Increasing MA enrol

94、lment may also improve or maintain quality of care.Though wide variation exists across plans,a meta-analysis comparing MA plans and all of Medicare FFS reported that 53percent of included studies found that MA plans outperformed on quality metrics,and 49percent found that MA plans drove better outco

95、mes(compared to 13 percent and 8 percent,respectively,for FFS).22However,these studies have limitations:direct comparison of quality across models is difficult due to substantially different approaches to performance evaluation(Exhibit 4).There are often wide differences in the kinds and quantity of

96、 metrics considered,and the weighting assigned to these metric areas often varies substantially.Rather than assess quality across models,we assess a more foundational question:how do different Medicare models approaches to performance evaluation differ,and how might these differences contribute to v

97、ariations in incentives and outcomes?Comparison of quality evaluationAmong accountable care relationships,the ACO modelssuch as MSSP in Alternative Payment Model(APM)Performance Pathway23 and ACO REACHevaluate a more targeted set of quality metrics.This reflects a potentially simpler and more scalab

98、le approach to quality performance.Providers say that focusing on a prioritized set of measures is less operationally burdensome and more easily harmonized with their existing quality processes.Furthermore,several measures that MSSP and REACH have both adoptedsuch as all-cause readmissions,chronic-c

99、ondition admissions,and days at home versus in the hospitalare related to cost of care.Such an approach may encourage more integrated efforts and potentially better performance across quality and cost parameters;many risk-bearing providers convey that,currently,these efforts are often disparate proc

100、esses.The other major area of divergence between ACO quality measurement and MAs quality program is the emphasis on patient experience.While these programs all use the Consumer Assessment of Healthcare Providers and Systems(CAHPS survey),performance in CAHPS can be more significant in MA given the r

101、ole the survey plays in determining MA Star ratings(more than 30 percent of scores in 2023)and associated bonus and rebate revenue.24 This suggests that MA plans and their network providers have incentives to invest as much in more holistic aspects of patients care journeys as they do in measures of

102、 claims-based outcomes.With CMMIs stated goal of incorporating more experience-related measures in future model deployments,stakeholders may anticipate a future in which investments in the patient journey earn greater return given their potential relevance for 100percent of Medicare beneficiaries.MI

103、PS may be the most comparable program in FFS to the performance initiatives in ACOs and MA,but it 10Looking ahead to the next decade of accountability for care deliveryis evaluated quite differently.25 The program places lower weight on comparable quality measures,considers ten times the number of q

104、uality metrics as any other model,and allows participants to select measures against which they are evaluated.Though many additional factors are at play,the complexity of MIPS may play a part in the observed quality differentials between Medicare FFS and accountable care relationships.Stakeholder im

105、plicationsIf 100 percent of Medicare beneficiaries are covered in accountable care relationships by 2030,the implications for providers,payers,and their partners would be meaningful.Exhibit 4Exhibit of Each accountable care model uses diferent metrics when calculating performance scores.McKinsey&

106、;CompanyInputs into performance scores across Medicare payment models,FY 2022,by metric type,%Note:Medicare FFS scoring mechanisms are scaled to remove cost because this is inherently accounted for in the risk-based Medicare Shared Savings Program(MSSP);ACO REACH(Accountable Care Organization Realiz

107、ing Equity,Access,and Community Health),and Medicare Advantage(MA)models;Figures may not sum to 100%,because of rounding.1FFS Merit-based Incentive Payment System(MIPS)model applies to Medicare FFS providers that qualify as eligible for MIPS and are not MIPS APMs.2Medicare FFS(all inpatient)model re

108、fers to 5 combined performance scoring models that evaluate all hospitals participating in Medicare FFS.3MSSP Alternative Payment Model(APM)applies to all MSSP participants that do not qualify as advanced APM qualifed entities;MSSP participants that do are entirely exempt from the improvement activi

109、ties and promoting interoperability categories.Three of the 9 required measures are fxed in the MIPS model;providers may select the remaining 6,although at least 1 must be an outcomes or“high priority”measure.4While ACO REACH includes 5 quality measures,the 4 used to evaluate performance are fxed de

110、pendent upon the model type.5Refers to Part C performance scores only.Source:ACO Realizing Equity,Access,and Community Health model:Request for applications,Centers for Medicare&Medicaid Services,February 24,2022;APM Performance Pathway(APP)Toolkit,CMS,2021;Hospital Inpatient Quality Reporting(I

111、QR)Program Measures,CMS,March 2022;Medicare 2022 Part C&D Star rating,CMS,October 4,2021;Overview of the 2022 Quality Payment Program Final Rule,CMS,November 10,2021Examples of MedicareFee-For-Service(FFS)evaluation modelsNumber of quality metrics requiredNumber of qualitymetrics available to se

112、lect fromFFS:MIPS1(clinicians)FFS:InpatientQuality Reporting program(hospitals)2MSSP:APM3 Performance PathwayACO REACH4MA:Stars59200404066452424192421366533333820305025132573336118Outcomes and intermediate outcomesProcessPatient experience and complaintsAccessProvider choice of quality metricsImprov

113、ement activitiesPromoting interoperabilityQuality metrics11Looking ahead to the next decade of accountability for care deliveryImplications for providersIf all or most Medicare beneficiaries are in accountable care relationships by 2030,providers serving this population may have little choice but to

114、 adopt aspects of a risk-bearing care delivery model.Moreover,given MA plans are increasingly pursuing risk-sharing arrangements with providers,strengthening value-based care capabilities could enable providers to serve a greater share of MA members while aligning care models across their patient pa

115、nel.Increasing scale of lives covered under risk for any provider would likely require investments in value-based care capabilities or partnerships with existing risk-bearing organizations.In our experience,success in accountable care arrangements has depended on the ability to share data;clinical l

116、eadership with a demonstrated willingness to make changes that impact performance(for example,hiring clinical and management or administrative personnel,updating processes,and changing referral patterns);good historical performance on prevention and chronic-disease management;demonstrated willingnes

117、s to use data and modify workflows;inclusion of value-based components in physician compensation models;dedication to accurate and complete diagnoses;and the capability and interest to work with the community on social determinants of health(SDoH).Along with their internal capabilities,providers suc

118、cess depends upon their value propositions and efficiency relative to other providers in their markets.Providers unique experience levels in bearing risk will inform their particular approaches:Providers with nascent risk-bearing capabilities may consider joining the network of an existing ACO to co

119、ntinue serving Medicare patients,achieve sufficient scale to bear risk,and justify capability investment.Alternatively,if these providers already have sufficient scale with strong enough funding and economic incentives to establish their own risk-bearing model,they may establish a stand-alone ACO or

120、 enter into arrangements with MA plans.Providers with some experience managing risk may conduct objective assessments of their value-based care capabilities and attributed patient claims history to understand improvement opportunities,especially because future models may further encourage downside r

121、isk or use stricter benchmarks.Additionally,providers less familiar with taking on risk specifically for Medicare beneficiaries may need to tailor their care management capabilities to these patients unique needs.Providers with demonstrated track records of successfully managing risk are positioned

122、for geographic or market expansion via provider network growth,new risk-bearing contracts across lines of business,and assumptions of greater levels of risk.Implications for population health vendorsGiven that the majority of providers likely fall into the first or second categories above,population

123、 health vendors that provide support in risk stratification,patient engagement,attribution analytics,performance management,organizational transformation,and other capabilities critical to success in risk-bearing models will likely see large opportunities for expansion.Particularly given the time,co

124、st,and experience required for providers to pursue organic capability building,these vendors could serve as important partners in spurring expeditious adoption of accountable care.Implications for private payersIn addition to ACOs in Medicare FFS,MAOs are also positioned for growth through 2030.Alth

125、ough CMMI considers ACOs to be different than MAOs,26 continued MA enrollment growth may be consistent with CMMIs long-term vision of payment for value.As such,MAOs may continue to increase their market presence and exert influence on care and payment innovation at the local,regional,and national le

126、vels.12Looking ahead to the next decade of accountability for care deliveryObjective 2:Advance health equityCMMI has stated a new objective of promoting health equity via its models,noting that past and current demonstrations often include fewer beneficiaries from underserved groups.Beneficiaries in

127、 the highest-income counties(relative to their states average per-capita income)are substantially more likely to be enrolled in an MSSP ACO compared with beneficiaries in the lowest-income counties.27 Given that Medicare ACOs and MA plans may drive better health outcomes than Medicare FFS,increasing

128、 enrollment of underserved populations in these programs alone could bolster health equity and reduce existing disparities.Furthermore,a clear CMMI strategy to advance health equity could create an impetus for stakeholders to build the capabilities necessary to address social needs in their patient

129、populations.A December 2021 McKinsey survey suggests that 87 percent of providers highly or somewhat prioritize SDoH efforts,but fewer than 30 percent of providers view their SDoH capabilities as strong.28 One such critical capability is patient screening and data collection.Using data to address he

130、alth disparitiesCMMI has identified data collection processes as an important enabler of widespread equity advancement.CMMI does not comprehensively require that demonstration participants collect and report patients self-reported sociodemographic and social needs data.CMMI does not yet have standar

131、ds in place to link these data(where they do exist)to beneficiaries claims and outcomes,although it has stated a goal of expanding and standardizing the collection and use of demographic data in the future.To address these points,CMMI in future models could consider several initiatives for which sta

132、keholders could prepare:1.Align data collection requirements for demonstration participants with those of Medicare broadly.For example,CMS currently collects Medicare beneficiaries age,race and ethnicity,language,place of residence,education,income,sex,and marital status.292.Adopt CMS or Medicare da

133、ta standards that facilitate linking sociodemographic data,encounter-level claims data,and downstream outcomes.This could double as an opportunity to promote interoperability among providers,community-based organizations,and publicly provided social services.CMMI could also partner with existing pub

134、lic collaborations aiming to promote standardization of sociodemographic and SDoH data.3.Expand the types of data collected to better understand and address health disparities.In addition to baseline sociodemographic data,demonstrations could also include screening data on unmet basic needs,housing

135、status,digital and health literacy,and broadband availability.CMS has independently indicated plans to expand SDoH and social needs data collection,and CMMI may leverage this broader effort in its own demonstrations.30A consistent data strategy by CMMI could help consolidate providers currently vari

136、ed approaches to collecting and using sociodemographic and social needs data.For example,Medicare has already created SDoH-related Z codes(ICD-10-CM31“encounter reason codes”for SDoH)to capture many SDoH needssuch as problems with housing or educationbut code use is extremely low;only 1.59percent of

137、 Medicare FFS beneficiaries had claims including Z codes in 2019.32 Similarly,the previously mentioned McKinsey survey found that while 72 percent of providers report conducting some form of social needs screening as part of their patient intake process,only 1 percent screen for the full set of basi

138、c unmet needs recommended by PRAPARE,a standardized assessment tool.33This lack of comprehensive adoption could be due to a variety of reasons:13Looking ahead to the next decade of accountability for care delivery Insufficient incentives:Providers may lack the ability to conduct and document social

139、needs screenings(such as upward payment adjustments).Rigid or burdensome workflows:Only about 50 percent of providers have built any sort of social needs screening into their workflows.34 Lack of institutional knowledge and awareness:Many providers do not have the knowledge of how to use generated S

140、DoH data or are unfamiliar with Z codes and similar documentation mechanisms.CMMI may consider integrating greater incentives and stakeholder education to address these barriers to adoption.CMMI may also consider integrating health equity tools that have demonstrated success in equity-focused progra

141、ms.Health equity tools from existing modelsCurrent CMMI models,state programs,and private payer and provider initiatives offer a set of potential design choices that could better promote health equity(Exhibit 5).Several of these approaches have reduced disparities for specific populations;some have

142、improved cost of care performance,as well.Such approaches include providing various Exhibit 5Web Exhibit of Several approaches to promote equity have been deployed in existing payment models.McKinsey&CompanyNote:SDoH stands for social determinants of health.1Fee-For-Service.2Center for Medicare&

143、amp;Medicaid Innovation.Source:“Addressing social determinants of health through Medicaid accountable care organizations:Early state eforts,”Centers for Health Care Strategies(CHCS),February 14,2018;“Blue Cross Blue Shield of Massachusetts becomes frst health plan in market to incorporate equity mea

144、sures into its payment models,”Blue Cross Blue Shield of Massachusetts,September 23,2021;CalAIM Overview;Carlton Houston,“Targeting health equity with community health workers leading the way,”Blue Cross Blue Shield,October 12,2021;Centers for Medicare&Medicaid Services(CMS);“MassHealth risk adj

145、ustment model:Social determinants of health,”Massachusetts Executive Ofce of Health&Human Services,October 14,2016;Tamara Baer,Erica Coe,Anne Kofel,and Jordan VanLare,“Patients struggle with unmet basic needs:Medical providers can help,”McKinsey,April 1,2022;Tamara Baer,Matthew Isaacs,Alex Mande

146、l,and Pradeep Prabhala,“How healthcare payers can expand nutrition support for the food insecure,”McKinsey,November 24,2021 Type of approachEquity toolMedicare FFS1 and CMMI2 demosMedicaid and state programsCommercial plansUsed by Quality and performance evaluations tied to payment Up-front funds to

147、 support care infrastructureEnhanced coverage,reimbursement,or cost-sharing supportEquity and SDoH metrics tied to paymentEquity and SDoH metrics tied to executive compensationEquity and SDoH benchmark adjustmentUp-front funds for providers supporting underserved groupsFunds for expanded care teams,

148、including community health and social workersUnmet basic needs screeningsLinkages to social supports or wraparound services(eg,housing,food,legal aid,transportation)Provision of social supports or wraparound servicesReduced cost-sharing for care disproportionately supporting underserved14Looking ahe

149、ad to the next decade of accountability for care deliverysocial supports and wraparound services,35 tying executive compensation to health equity metrics,36 and administering funds up front to providers supporting underserved groups.37Preparing for new modelsDeploying most tools in Exhibit 5 require

150、s complete,accurate sociodemographic and social needs data as well as the ability to link such data to downstream outcomes.As such,investments in these areas will be important for providers,payers,and states looking to advance health equity and perform effectively in future CMMI demonstrations.Furth

151、ermore,screening and data collection enable organizations to identify and stratify health disparities among their patient populations,but narrowing such disparities requires that these patients are connected with the proper interventions.Today,only 45 percent of providers offer closed-loop referral

152、services to various social supports,and less than half offer specific programming themselves to address transportation,housing,and food security needs.38 Stakeholders that strengthen relationships with social-service and community-based organizations and vendors of other wraparound services will be

153、better positioned to make improvements in patient equity.If CMMI continues to expand reimbursement for health-related support services,organizations that provide these services are likely to see increased demand as they establish partnerships and strengthen referral pipelines with demonstration part

154、icipants.Objective 3:Support care innovationsCMMIs third objective is to promote innovative,patient-centered care.We discuss opportunities in two specific areas:patient experience and provider enablement.Prioritizing the patient experienceIn its strategy refresh,CMMI communicated its intent to incor

155、porate patient experience measures and patient-reported outcomes in future models performance measurement.This new priority closely mirrors the doubled weight of member or patient experience in the Medicare Advantage Stars program that begins in rating year 2023.39Types of patient experience measure

156、s that stakeholders might see CMMI adopt include the following:Operational and access metrics such as those used in the Healthcare Effectiveness Data and Information Set(HEDIS)toolfor example,a percentage of patients receiving a case management call within 48 hours of a discharge or the average wait

157、 time to receive an appointment Patient-reported experience measures such as cultural competency of care received(in alignment health equity objectives),level of satisfaction with practices physicians and staff,and the degree of personalized care received CAHPS scores or a subset of CAHPS metrics(in

158、 alignment with MSSP APM Performance Pathway APP)Based on our primary research with ACO participants,providers may have mixed reactions to integrating the patient experience with performance measurement.On one hand,regular,systematic assessments of how an organizations patient experience compares to

159、 that of peers would be beneficial to understanding market perception and competitive opportunities.Additionally,tying model economics to patient experience could strengthen the rationale for acting on performance improvement plans,for which the conviction to make investments can falter.However,our

160、research suggests that providers may have reservations about penalties based on patient-reported measures,particularly in more subjective areas.CAHPS surveys,for example,can be challenging for ACOs given that FFS beneficiaries are free to see providers outside the preferred network and may conflate

161、their experiences when responding.Smaller organizations may also struggle with the cost of running patient outreach initiatives 15Looking ahead to the next decade of accountability for care deliverysuch as CAHPS;private payers have remitted per-member-per-month(PMPM)funding for conducting such activ

162、ities to support providers in this regard.Strengthening provider enablementCMMI articulated an additional goal of providing more real-time data and insights to ACO participants.Our primary research indicates that providers would find such support valuable to their care management programs.Gaps in lo

163、ngitudinal patient data are meaningful obstacles to success in ACO models,particularly in management of the highest-risk beneficiaries for whom quality and equity of care is also a challenge.Because of the open network of Medicare FFS,most ACOs struggle to capture more than two-thirds of patient enc

164、ounter data,at most.40 This dynamic creates discontinuities in management of attributed lives,which can result in care gaps and missed intervention opportunities;worsened patient experience and care quality;and financial losses for the ACO.To address this pain point,many ACOs turn to vendors that ag

165、gregate and share patient encounter data across the local area.However,this approach still poses several issues:Vendors often share data that are duplicative or extraneous to what an ACO needs while fragmenting the organizations data model,inhibiting ingestion and consumption efforts.Some data gaps

166、usually remain(for example,not every provider in a region will participate on the platform).The financial barrier is often high for smaller providers to purchase these solutions,inhibiting the smallest and most financially precarious providers from adopting accountable care.As such,a more exhaustive

167、 and native source of real-time patient data could create substantial value for patient care and ACO performance.Providers under MA contracts often receive such measures(detailed below)from plans within 72 hours via web-based portals.A similar approach could be taken by CMMI in the future.Shared dat

168、a most valuable to risk-bearing providers often includes the following:real-time patient attribution attributed patients care encounters at other facilities attributed patients cumulative claims(with breakouts across care settings)spend variance across patients and providers,by service line risk-str

169、atified patient engagement prioritization average and segmented risk scoresObjective 4:Improve access by addressing affordability CMMIs second objective is to improve affordability for beneficiaries by reducing out-of-pocket(OOP)costs,with the ultimate goal of increasing access to care.Current affor

170、dability challenges and related CMMI demonstrationsIn 2017,approximately one-quarter of all Medicare beneficiaries spent 20 percent or more of their income on medical care.41 High OOP costs can contribute to forgoing necessary care and prescription drugs.42 OOP costs tend to be highest for beneficia

171、ries in Medicare FFS without supplemental coverage such as Medigap,and those in MA plans often face a lower cost burden.43To date,CMMI has deployed numerous demonstrations to reduce overall program costs,but few have aimed to directly reduce consumer OOP costs.Examples of some that have sought to di

172、rectly tackle beneficiary costs include the Value-based Insurance Design MA(through redesign of cost-sharing rates and expansion of supplemental benefits)and Part D Senior Savings models(by 16Looking ahead to the next decade of accountability for care deliverysetting caps on OOP insulin costs).CMMI

173、may take further action on drug savings models following an October 2022 executive order that asked CMMI to consider new healthcare payment and delivery models that would lower drug costs and promote access to innovative drug therapies in Medicare and Medicaid.44 Scaling accountable care could unloc

174、k some FFS beneficiary cost reductions to the extent that Medicare generates and passes on a portion of program efficiencies.The impact of 100 percent accountable care enrollment on OOP costsTransitioning to 100 percent accountable care enrollment by 2030 could create beneficiary cost reductions,but

175、 the overall level of relief substantially depends on ACO savings performance and the extent to which these efficiencies are passed on to consumers(Exhibit 6).ACO savings have varied by design and participating entitiesfor example,physician-led ACOs have generated higher savings than hospital-led AC

176、Os.45 Furthermore,attributing savings to specific ACOs can be difficult given overlapping models.CMMIs new strategy may reduce its number of models,which may help address issues with overlap.46To assess the OOP relief potential from being enrolled in accountable care,we used the performance scenario

177、s constructed in the previous Exhibit 6Web Exhibit of While certain changes by 2030 may result in out-of-pocket savings,such savings depend on model type and performance.McKinsey&CompanyProjected 2030 out-of-pocket(OOP)costs for Medicare FFS1 benefciaries,$Assumes 35%of generated savings passed

178、on to benefciaries(via premium reductions),varied by ACO performance2Note:ACOs stands for accountable care organizations.1Fee-For-Service.235%pass-through rate estimated as ratio of total consumer expenditures vs total government expenditures.Scenarios vary uptake across 1-sided,2-sided,and full cap

179、itation models(risk type)and savings rates(using diferent Center for Medicare&Medicaid Innovation CMMI models as baseline and assuming diferent rates of improvement).Model accounts for Advanced Alternative Payment Model(AAPM)bonus payments.Source:“Benefciaries who switch to Medicare Advantage ha

180、ve lower Medicare spending and use fewer services in the prior year than those who stay in traditional Medicare,”KFF,May 7,2019;David Mike and Gokce Yilmaz,Average annual benefciary health care costs for various Medicare coverage options,Millman,January 2021;Jeannie Fuglesten Biniek,Juliette Cubansk

181、i,and Tricia Neuman,“Higher and faster growing spending per Medicare Advantage enrollee adds to Medicares solvency and afordability challenges,”KFF,August 17,2021;Juliette Cubanski et al.,“How much do Medicare benefciaries spend out of pocket on health care?,”KFF,November 4,2019;“National health spe

182、nding in 2020 increases due to impact of COVID-19 pandemic,”Centers for Medicare&Medicaid Services(CMS),December 15,2021;Michael Zhu et al.,“The Medicare Shared Savings Program in 2020:Positive movement(and uncertainty)during a pandemic,”Health Afairs,October 14,2021Medicare FFSLowperformanceMid

183、dleperformanceHighperformanceMedicare FFS:ACOs10,36510,37510,1109,693Other OOPPremiumsOOP savings6,0104,3556,0104,3656,0104,1006,0103,6822556731067317Looking ahead to the next decade of accountability for care deliverysection and assumed that 35 percent of Medicares generated savings are passed on t

184、o consumers.47(Notably,Part Bs 20 percent beneficiary coinsurance would vary based on Part B spending changes.)This results in beneficiaries in the low-performance scenario seeing increased annual OOP costs of$10(assuming these cost excesses are passed on to enrollees),while those in the middle-and

185、high-performance scenarios may see annual OOP savings of$255 and$673,respectively.To contextualize these figures,OOP savings in the highly ambitious high-performance scenario are just 6.5 percent of projected OOP costs for Medicare FFS beneficiaries in 2030.These findings suggest that without broade

186、r affordability initiatives,the potential of ACOs will continue to be primarily in reducing costs at a system level rather than a beneficiary level.By contrast,MA plans have often delivered greater consumer affordability(via premium support and reduced cost sharing),enabled,in part,by higher payment

187、s at the system level.One study found that in 2020,the average Medicare beneficiary would have spent 37 percent less,on average,when enrolled in an MA plan than when in Medicare FFS,and that this differentiated affordability increases as beneficiaries age.48 In addition to higher plan payment levels

188、,these lower OOP enrollee costs are often enabled by limiting the size of provider networks,care management,prior authorization for high-cost treatments,payment reductions to providers,novel arrangements with providers(which may vary in quality),and other cost-saving measures.Given the limits of inf

189、luencing affordability purely via ACO efficiencies and the trade-offs in doing so via MA,CMMI has indicated that it is considering broader opportunities to reduce the average beneficiary cost burden.For instance,targeting price rather than quantity may be an effective approach to lowering overall he

190、althcare costs;several studies have found that price differences could drive most differences in health spending between the United States and peer countries.49Stakeholders could prepare for several such initiatives targeted at price.CMMI articulated that it would continue to pursue site-neutral and

191、 episode-based payments as well as encourage increased biosimilar uptake.However,as CMMI acknowledges,there are challenges to meaningfully scaling increased affordability with these initiatives.A broader CMS initiative that is related to CMMIs goal of affordability is the required disclosure of hosp

192、ital-and payer-negotiated prices.As industry leaders think through opportunities for accountable care relationships,it would be important to understand how CMMI models will integrate with other CMS processes and decisions.Leveraging price transparency to bring down pricesAs of January 2021,CMS has r

193、equired that hospitals disclose their full set of negotiated and out-of-network rates along with self-pay rates for top shoppable services.Similarly,as of July 2022,payers are required to disclose their own negotiated rates and will eventually need to make personalized out-of-pocket cost information

194、 for all covered items and services available to enrollees.These rules are intended to encourage consumer shopping behavior that could then drive down prices,particularly prices not rationalized by quality and scale considerations.If these consumer behaviors take hold throughout the entire system,pr

195、oviders may need to enhance their value propositions by strengthening the patient experience or rationalizing higher-than-expected prices to remain competitive in many markets.Any such marketwide changes to provider value and price sensitivity may affect not only privately insured patients but also

196、Medicare and Medicaid patients.However,the latest price transparency rules from CMS are not guaranteed to lower prices;providers and payers signal that the local market dynamics(for example,provider concentration,employer preferences,and patient loyalty)would have a substantial impact on the extent

197、to which prices decrease or decelerate.Furthermore,consumer sensitivity to OOP costs is essential to payers ability to reduce or slow the growth of negotiated rates.However,insured patients insulation from gross 18Looking ahead to the next decade of accountability for care deliveryprices could inhib

198、it consumer adoption of price transparency toolsthat is,consumers may be less encouraged to actively select high-value services if their deductible and cost sharing is low.Objective 5:Promote partnerships to achieve care transformationCMMIs last objective is to promote partnerships across public and

199、 private stakeholders and drive multipayer alignment to better align system incentives.Approach to partnershipsPartnerships with organizations beyond demonstration participants may serve to facilitate the scale of accountable care,particularly those that ease barriers to model participation and coll

200、aboration.CMMI partnerships with public-and private-sector stakeholders could provide different strategic value to demonstration participants.Case studies of prior partnership strategies may serve as a guide for future partnerships.Pursuit of multipayer alignment:A state-level case studyOne state-ba

201、sed multipayer program that could serve as a model for broader efforts is the Arkansas Health Care Payment Improvement Initiative(AHCPII),which demonstrated the early impact of accountable care models.Started in 2012,AHCPII was spearheaded by Arkansass state Medicaid program and convened public and

202、private payers to design a program focused on cost and quality of care.The program deploys two strategies:a multipayer patient-centered medical home(PCMH)and a retrospective episodes of care model.50Within the first 2 years of AHCPIIs deployment,the state Medicaid program reduced cost of care by 8pe

203、rcent(compared with projected),hospitalizations by 16.5 percent,and emergency room visits by 5.6 percent.Select commercial payers reduced cost and length of stay for certain episodes of care by 5 to 20 percent.Across both types of payers,40 to 75 percent of all quality measures were maintained,impro

204、ved,or satisfied requirements.51Stakeholders may look to the design choices of AHCPII as they prepare for future deployments of payment models and demonstrations aligned across payers(Exhibit 7).Other partnership models in care innovationIn addition to partnerships across payers,CMMI might consider

205、partnerships with other public-and private-sector organizations.CMMIs last objective is to promote partnerships across public and private stakeholders and drive multipayer alignment to better align system incentives.19Looking ahead to the next decade of accountability for care deliveryPartnerships a

206、cross government programs can help to facilitate sharing of best practices and to align quality metrics,plan design,and provider incentives.In one example,Washington state participated in a MedicareMedicaid partnership that adds care coordination as a Medicaid-covered benefit.The model has resulted

207、in nearly$300 million in net government savings over its first six years and 85percent of beneficiaries expressing satisfaction with care coordination services.52 A more recent example is the potential partnership between the US Department of Health and Human Services and the US Department of Housin

208、g and Urban Development on a joint housing and services resources center that brings support and resources for housing and related services,including Medicaid-funded home-and community-based services(HCBS).53Partnerships across community-based,social-services,population health management,and risk-sh

209、aring organizations can facilitate evaluation,boost upstream engagement,improve risk stratification,and increase investments in social determinants.For example,the ACO Aledade and providers partnered to establish MSSP ACOs,Exhibit 7Web Exhibit of Arkansass multipayer model improves the quality of pa

210、rtnerships and aligns payers.McKinsey&Company1Dual Eligible Special Needs Plans.2Managed care organization.3Primary care physicians.4Patient-centered medical home.Source:Financial Alignment Initiative guidance,Centers for Medicare&Medicaid Services,April 17,2013;“HHS and HUD announce expande

211、d partnership,new Housing and Services Resource Center,”US Department of Housing and Urban Development,December 8,2021;“Independent practices working with Aledade will earn more than double in shared saving this year across all payers,despite pandemic,”Aledade,July 22,2021;“NCCARE360,”North Carolina

212、 Department of Health and Human Services;Stephanie Carlton,David Malfara,Kevin Neher,and Cara Repasky,“New Stars ratings for Medicare Advantage prioritize customer experiences,”McKinsey,October 15,2020;Stephanie Carlton,Jessica Kahn,and Mike Lee,“Cascade Select:Insights from Washingtons public optio

213、n,”Health Afairs,August 30,2021;“Vermont All-Payer ACO model:Annual health outcomes and quality of care report:Performance year 1(2018),”Green Mountain Care Board,April 7,2020 Resources for primary care practice transformation and care coordination are a major piece of the all-payer strategy toward

214、transitioning the state to value-based care Common defnition of episodes of care enables providers to approach care in a consistent manner and pursue the same fnancial incentives across payers Providers have access to a common platform across payers to report and track performance against core quali

215、ty metrics D-SNPs1 and Qualifed Health Plans are required to participate,while group plans and employers were convened via state leadership and infuence on MCO2 payers Provider participation is voluntary,but fewer than 85%of PCPs3 and practices have enrolled In early years of the PCMH4 model,PCP pra

216、ctices earned shared savings on attributed patients total cost of care;however,the annual benchmark-setting processes became more complex than the state could manage,and the program was eventually transitioned to one of quality metrics and performance-based incentive payments“Episodes of care”progra

217、m consists of 14 defned episodes,each with expected cost thresholds(set independently by each payer)against which providers are measured Level of risk sharing varieseg,performance reporting only,upside only,and upside and downside have all been tested;a spectrum of fnancial responsibility could serv

218、e as a glide path toward full accountability for cost and quality of careApproachParticipationDesign20Looking ahead to the next decade of accountability for care deliverywhich saved Medicare$300 million in 2020 across 410,000 beneficiaries.54 Examples of additional care networks include North Caroli

219、nas NCCARE360 and Unite Virginia,which establish state and vendor partnerships to offer platforms linking social services and healthcare organizations that support referrals and outcomes tracking.55ConclusionFor the past decade,CMMI has signaled what lies ahead for US healthcare.An emphasis on popul

220、ation health,investments in primary care,and increases in home health are examples of trends that CMMI has supported and helped spur.As such,CMMIs renewed strategic vision for the next decade contains valuable indicators for what US stakeholders could expect next.In particular,the broadened aspirati

221、ons of this vision convey the heightened importance of newer areas such as care innovation and health equity.Several of these new priorities are ones for which future demonstration participants will be held accountable;whether it is measurement of patient experience,narrowing of health disparities,o

222、r aligning payment across payers,the success of many stakeholders will depend on development of different capabilities and learning to operate in new ways.Data collection investments,patient journey enhancements,community partnership building,sharing more model data with industries,and care manageme

223、nt improvements are examples of capabilities to prioritize.However,a large part of CMMIs vision is a continuation of previous priorities,with an aspiration for scale.Namely,striving for nearly all Medicare and Medicaid beneficiaries to be enrolled in accountable care relationships by 2030 is a susta

224、ined pursuit of paying for value rather than volume.More than 23 million additional Medicare lives may be covered under ACO arrangements in the next eight years if CMMIs aspiration is realized,and this will not be possible without ambitious moves toward value-based care by stakeholders.These trends

225、may reverberate to other sources of coverage as well,including in Medicaid with the support of state partners,and in commercial segments if the overall healthcare landscape evolves in CMMIs direction.These new imperatives create new opportunities.Because of the COVID-19 pandemic,consumer expectation

226、s and behaviors have evolved,some permanently.Providers,payers,and innovators can adapt their models to deliver and pay for care that meets top-down signals from the federal government and bottom-up expectations from their own patient populations.Realizing these opportunities will require organizati

227、ons to build the leadership,knowledge,and capabilities to make and direct this change across the US healthcare system.Scan Download PersonalizeFind more content like this on the McKinsey Insights AppZahy Abou-Atme is a partner in McKinseys New York office,Stephanie Carlton is a partner in the Dallas

228、 office,and Isaac Swaiman is a senior expert in the Minneapolis office.The authors wish to thank Fadesola Adetosoye,Tamara Baer,Camille Gregory,Drew Guerra,Jeet Guram,Omar Kattan,Alok Ladsariya,Alex Mandel,Michael Morley,Arjun Prakash,Suzanne Rivera,Jordan VanLare,and Zoe Williams for their contribu

229、tions to this report.Designed by McKinsey Global PublishingCopyright 2022 McKinsey&Company.All rights reserved.21Looking ahead to the next decade of accountability for care delivery1 H.R.3590-Patient protection and affordable care act,Sec.3201,US Congress,March 23,2010.2 Innovation Center strate

230、gy refresh,Centers for Medicare&Medicaid Services(CMS),October 20,2021.3 Brad Smith,“CMS Innovation Center at 10 years Progress and lessons learned,”New England Journal of Medicine,2021,Volume 384,Number 8.4 Because this article focuses on helping readers understand federal(not state)government

231、signals,we discuss Medicare only.5 Also known as Part A of Medicare,the Hospital Insurance Trust Fund finances healthcare services for stays in hospitals,skilled-nursing facilities,and hospices for eligible beneficiariesmainly people over 65 with a sufficient history of Medicare contributions.6 For

232、background on the inner workings of accountable care organizations(ACOs),see“The math of ACOs,”McKinsey,August 19,2020.7 Enrolled in Medicare Parts A and B;Innovation Center,October 20,2021.8 Ibid.9 CMMI uses innovative payment design models(called demonstrations)to test potential changes to traditi

233、onal Medicare payment policies.10Innovation Center,October 20,2021.11 2022 Medicare Trustees report,CMS,November 30,2020;assumes all Medicare beneficiaries are enrolled in Part A and B for purposes of CMMIs objective of ensuring all beneficiaries with Parts A and B coverage will be in an accountable

234、 care relationship.122022 Medicare Trustees report,November 30,2020.13 The Census Bureaus projections on population growth over the period 202126(for more,see 2017 National Population Projections Tables:Main Series,US Census Bureau);Robert Wood Johnson Foundations estimates on avoidable spending as

235、rate of hospital stays for ambulatory caresensitive conditions for Medicare beneficiaries as of 2019;CMS data on the population disease burden defined as the average risk score across all Medicare enrollees as of 2020(for more,see County-level Aggregate Expenditure and Risk Score Data on Assignable

236、Beneficiaries,CMS,2021);“use of alternative care setting”refers to Truvens data on the usage of ambulatory surgical centers as of 2019.14 Notably,this does not include CMMI ACO-like demonstrations,which cover approximately 3.5 percent of Medicare beneficiaries,for which detailed geographic enrollmen

237、t data are not available.15 A geographic area(defined by the Office of Management and Budget)that CMS uses to define the payment areas for the hospital wage index.16 Defined as bottom 50 percent of aggregate penetration and top 50 percent of value-generating opportunity.17“Medicare Shared Savings Pr

238、ogram saves Medicare more than$1.6 billion in 2021 and continues to deliver high-quality care,”Newsroom,August 30,2022.18 Based on 2030 projected Medicare expenditures from National Health Expenditure(NHE)projections from 2021 annual report of the Boards of Trustees of the Federal Hospital Insurance

239、 and Federal Supplemental Medical Insurance trust funds,CMS,2021.19 Gross-savings rate was used to illustrate the maximum possible savings to the program if ACOs were only compensated based on advanced alternative payment model(AAPM)bonuses and to illustrate the savings generated if ACOs operated ne

240、ar Medicare Advantage(MA)bid efficiency.20 Fierce Healthcare;CMS targets reforms to benchmarks to kick-start flat ACO participation.21“Medicare program shared savings accountable care organizations have shown potential for reducing spending and improving quality,”Department of Health and Human Servi

241、ces,August 2017;“Medicare ACOs continue to succeed in improving care,lowering cost growth,”CMS,November 10,2014;“Performance year financial and quality results,”CMS,last modified August 30,2022.22 Eva DuGoff et al.,“Quality,health,and spending in Medicare Advantage and traditional Medicare,”American

242、 Journal of Managed Care,September 2021,Volume 27,Number 9;however,“Some Medicare Advantage organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care,”US HHS Office of the Inspector General,April 27,2022 found that some MA plans denied p

243、rior authorization requests and payments that should have been covered and were medically necessary.This further highlights quality variation across MA plans and the difficulties with definitively evaluating MA plan quality and outcomes versus those of Medicare FFS programs.23 MSSP participants that

244、 qualify as advanced APM qualified entities are excluded from the improvement and interoperability measures and related MIPS payment adjustments but still must achieve baseline APM Performance Pathway(APP)quality thresholds.Endnotes22Looking ahead to the next decade of accountability for care delive

245、ry24“Medicare 2022 Part C&D star ratings technical notes,”CMS,updated October 4,2021.25 Providers may voluntarily choose two out of three measures against which they are evaluated(from 200 choices,70 percent are process oriented and 1 percent are on customer experience),and one of the selected m

246、easures must be either a“high priority”or outcomes measure;“2022 quality measures:Traditional MIPS,”Quality Payment Program,accessed September 12,2022;McKinsey analysis.26“Whats the difference?:Accountable care organizations and Medicare Advantage,”CMS,October 2022.27 High-income counties are those

247、in the top 20 percent of counties by average per capita income relative to their respective states;lowest income are in the bottom 20 percent of counties.Excludes Medicare Advantage enrollees from analysis and compares county-level enrollment in MSSP versus total eligibility for Medicare FFS(and not

248、 enrolled in MA);Academic studies of the MSSP,Pioneer,and Next Gen ACO models find beneficiaries are less likely to be disabled,less likely to be dual-eligible,less likely to identify as Black or Hispanic,less likely to live in rural areas enrollment,and less likely to be impoverished;“Next Generati

249、on accountable care organization model evaluation,”NORC at the University of Chicago,September 2020;Arnold M.Epstein et al.,“Analysis of early accountable care organizations defines patient,structural,cost,and quality-of-care characteristics,”Health Affairs,2014,Volume 33,Number 1;Carl Vidrine,“Spec

250、ial report:Analyzing 2020 ACO results and factors for success,”CareJourney,September 27,2021;CareJourneys external study used the Economic Innovation Groups Distressed Community Index to assess several factors(including income)and found that MSSP beneficiaries were concentrated in“prosperous”and“com

251、fortable”communities(the two highest-rated communities by the index);CMMIs internal studies reported similar findings to the academic and CareJourney studies regarding participation at the participating provider level;model participation is lower in underserved areas;Dora Lynn Hughes,“CMS Innovation

252、 Center launches new initiative to advance health equity,”Health Affairs,March 3,2022.28 Tamara Baer,Savannah Leonard,Alex Mandel,and Jordan VanLare,“How providers are meeting patients basic needsand where they could do more,”McKinsey,August 11,2022.29“Chronic Conditions Warehouse:Medicare administr

253、ative data user guide,”CMS,as of February 2022;“2018|Data users guide:Public use file,”Medicare Current Beneficiary Survey,2018.30“CMS proposes physician payment rule to improve health equity,patient access,”CMS,July 13,2021.31 International Classification of Diseases 10th Revision Clinical Modifica

254、tion.32“Utilization of Z Codes for social determinants of health among Medicare fee-for-service beneficiaries,2019,”Data Highlights from CMS,September 2021,Volume 24,Number 24.33 See the PRAPARE website;“How providers,”August 11,2021.34“How providers,”August 11,2021.35 Mekdes Tsega et al.,“Review of

255、 evidence for health-related social needs interventions,”The Commonwealth Fund,July 1,2019.36 Michele Cohen Marill,“Raising the stakes to advance equity in Black maternal health,”Health Affairs,2022,Volume 41,Number 3.37“Accountable health communities:Evaluation of performance years 13(20172020),”CM

256、S,December 18,2020.38“How providers,”August 11,2021.39 Amy Amick,“Medicare Advantage Star ratings:The new patient experience imperative for health plans,”Managed Healthcare,September 25,2020.40 Based on interviews with executives of leading ACOs.41 Karen Davis,Cathy Schoen,and Amber Willink,“Medicar

257、e beneficiaries high out-of-pocket costs:Cost burdens by income and health status,”The Commonwealth Fund,May 12,2017.42 M.Karpman et al.,“In the years before the COVID-19 pandemic,nearly 13 million adults delayed or did not get needed prescription drugs because of costs:Finding from the 20182019 Med

258、ical Expenditure Panel Survey,”Robert Wood Johnson Foundation,December 1,2021.43 Jeannie Fuglesten Biniek et al.,“Cost-related problems are less common among beneficiaries in traditional Medicare than in Medicare Advantage,mainly due to supplemental coverage,”Kaiser Family Foundation,June 25,2021.44

259、 Joseph Biden,“Executive order on lowering prescription drug costs for Americans,”The White House,October 14,2022.45 John Feore and Gabriel Sullivan,“Physician-led accountable care organizations outperform hospital-led counterparts,”Avalere,October 15,2019.46 Innovation Center,CMS,October 20,2021.47

260、 The pass-through rate is equal to the ratio of average OOP spending for Medicare beneficiaries compared to overall 23Looking ahead to the next decade of accountability for care deliveryper-beneficiary Medicare expenditures,from 2016 to 2019.While it is an assumption for the analysis that savings in

261、 Part A are passed on to beneficiaries,savings in expenditures for Part B services are directly linked to reduced beneficiary costs,given that the 20percent coinsurance rate is tied to Medicare payments.48 David Mike and Gokce Yilmaz,“Average annual beneficiary health care costs for various Medicare

262、 coverage options,”Milliman,January 2021;beneficiary healthcare cost estimates include premiums and cost sharing for medical services,pharmacy services,and ancillary services,such as dental,vision,and hearing;comparison is between Medicare Advantage prescription drug(MA-PD)plans and Medicare FFS wit

263、h prescription drug plans(PDPs).49 Gerard F.Anderson,Peter Hussey,and Varduhi Petrosyan,“Its still the prices,stupid:Why the US spends so much on health care,and a tribute to Uwe Reinhardt,”Health Affairs,2019,Volume 39,Number 1.50 A patient-centered medical home is a model in which a patients care

264、is spearheaded by a primary care physician who coordinates all types of care(acute,chronic,and preventative)with providers across the healthcare ecosystem(specialists,hospital,and home health);retrospective episodes of care is a model in which a provider is paid to coordinate all services furnished

265、to treat a clinical condition or perform a specific procedure(for example,hip replacement),and the fee is calculated before the service is provided and then reconciled against fee-for-service medical claims to determine shared savings after the episode ends.51“Arkansas Health Care Payment Improvemen

266、t Initiative:A spotlight on the 3rd annual statewide tracking report,”Arkansas Center for Health Improvement,April 2018.52“Washington health home MFFS demonstration:Fifth evaluation report,”RTI International,January 2022.53“HHS and HUD announce expanded partnership,new housing and services resource

267、center,”US Department of Housing and Urban Development,December 8,2021.54“Independent practices working with Aledade will earn more than double in shared savings this year across all payers,despite pandemic,”Adelade,July 22,2021.55“NCCARE360,”NC Department of Health and Human Services,accessed September 13,2022;see the Unite Virginia website.24Looking ahead to the next decade of accountability for care deliveryNovember 2022 Copyright McKinsey&C McKinsey McKinsey