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Clinical Advisory Group Subcommittee Meets to Discuss VBP for Medicare-Medicaid Managed Care Plans

The Department of Health (DOH) convened a subcommittee of the Managed Long Term Care (MLTC) Clinical Advisory Group on Nov. 6th to discuss value-based payment (VBP) arrangements under "integrated" managed care plans that cover both Medicare and Medicaid benefits, such as Fully-Integrated Duals Advantage (FIDA) plans, Medicaid Advantage Plus (MAP) plans, and Programs of All-Inclusive Care for the Elderly (PACE). The slides from the meeting are available here.

The Department reviewed the VBP models and levels of risk outlined in the state's Medicaid VBP Roadmap and described the opportunity for integrated plans to align financial incentives to promote better outcomes at a lower overall cost. DOH staff reiterated that for the MLTC population (including those beneficiaries enrolled in integrated plans), the Roadmap envisions VBP arrangements that cover the "total cost of care" and all of the benefits that are included in the plan's benefit package. Moreover, under the Roadmap, the VBP arrangements for integrated plans must involve greater levels of risk than those for partially-capitated plans.

While the Roadmap permits pay-for-performance arrangements to qualify as VBP under the partially-capitated MLTC program, it requires integrated plans to engage in VBP arrangements that involve shared savings, two-sided risk, or capitation. In order to contract with plans to assume a share in savings or losses across the entire benefit package, while achieving quality benchmarks, providers will likely be required to create or join 'integrator' entities, such as accountable care organizations (ACOs) or independent provider associations (IPAs). The Department acknowledged that the risk associated with two-sided VBP arrangements is elevated in integrated plans by low enrollment numbers and even lower numbers of enrollees in any single plan served by any given provider. A single beneficiary with unusually high costs could destabilize the arrangement. To mitigate this risk, the Department is recommending that shared risk arrangements involve at least 1,000 beneficiaries. However, it recognizes that most integrated plans cover fewer than 1,000 beneficiaries, and each network provider serves only a small fraction of each plan's total enrollment.

The Department queried participants regarding the most appropriate provider entity to take the lead in VBP arrangements with integrated plans (i.e., physician practices or long term care entities) and about the respective roles of plans and providers in care coordination. Unfortunately, technical problems interrupted the meeting. These questions will be discussed in greater depth at a follow-up meeting that is tentatively scheduled for November 9 at 11:00 a.m.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124