Below is an excerpt from a recent paper written by Manatt Health and the American Medical Association. Click here to read the full paper and case studies.
VBC models—especially those that seek to optimize quality and outcomes while minimizing costs—deliver real value. With a decade of performance results, Medicare Accountable Care Organizations (ACOs) have outperformed non-ACO physician groups on quality and have generated year-over-year savings for the Medicare Trust Fund[1]. However, adoption has been slow. In 2022, 90% of all US health care payments flowed through arrangements built on a fee-for-service architecture, while only 10% were in population-based payment arrangements. Overall, a quarter of payments flowed through two-sided financial risk contracts[2].
In addition to the Affordable Care Act in 2010, which incentivized the migration from fee-for-service reimbursement to value-based payment, there have been strong forces promoting the development of new value-based models of care. The COVID-19 pandemic prompted a surge in the use of digital technologies, as well as a greater awareness of the importance of social drivers of health. Innovative care models that have since emerged, including digitally enabled models, aim to deliver value by improving convenience and access for patients, addressing unmet social needs and promoting enhanced patient self-management, thereby improving outcomes and reducing cost.
The AMA has continued to develop robust educational content, best practices and playbooks for physicians to encourage broad adoption of innovative VBC models. For this research, the AMA set out to understand the CPT® code set’s role in VBC. The AMA gathered various stakeholder perspectives, including VBC provider organizations, health plans, integrated delivery systems, VBC enablement organizations, health technology organizations and others[3]. This issue brief is the culmination of these conversations, highlighting how CPT serves as the common language for VBC today and identifying areas for evolution. The AMA and the CPT Editorial Panel are committed to progressing the code set to ensure it continues to evolve in ways that support the delivery of high-value care to patients, and meets the needs of physicians, health professionals, health systems, policymakers and payers.
Today, the CPT code set serves as a critical enabler of three key pillars of VBC success:
- Population health and quality management
- Cost management
- Alternative payment model contracting
And plays a critical role across the full spectrum of risk models:
Click here to read the full study and case studies.
[1] Centers for Medicare & Medicaid Services (CMS). Participation Continues to Grow in CMS’ Accountable Care Organization Initiatives in 2024; Jan. 29, 2024. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ama-assn.org/system/files/vbc-best-practices-playbook.pdf. Accessed Sept. 19, 2024.
[2] Health Care Payment Learning & Action Network (HCPLAN). 2023 Measurement Effort; Oct. 30, 2023. https://hcp-lan.org/apm-measurement-effort/2023-apm/. For an orientation to value-based payment models, see https://hcp-lan.org/apm-framework/. Accessed Sept. 19, 2024.
[3] Interviews were conducted with over 40 individuals across 34 organizations.