In 2021, the Centers for Medicare & Medicaid Services (CMS) set a goal of having 100 percent of Medicare beneficiaries in an accountable care relationship by 2030. Since then, CMS has been enthusiastically pursuing systemwide health care reform for whole-person centered, equitable, accountable care. This means that an increasing number of beneficiaries will be attributed to or enrolled with a payor whose payment is tied to quality and health outcomes.

Primary care has been and continues to be the foundation for achieving CMS' goal. However, CMS has noted the importance of an accompanying specialty care strategy to ensure the goal is met and participants get the best care possible that best aligns with their needs. In executing its vision, CMS is choosing to focus on a few models, in order to strengthen and enhance these models to create a longitudinal interplay of coordinated primary and specialty care in which the provider is responsible for improved outcomes and total cost of care.

What Does This Mean for Long Term​ Care Providers?

Accountable care organizations (ACOs) and managed care are here to stay. The question is whether long term care (LTC) providers will take the initiative and lead in this evolving landscape or continue to be managed. Despite all the headwinds, including unprecedented workforce challenges, LTC providers need to pay attention, learn, assess their organization's current status in today's value based environment, identify their short and long term goals, and start exploring paths forward that align with these goals. They need to consider what role they want to play in this health care ecosystem in which the vast number of payments are no longer coming directly from CMS but rather through a “broker."

Providers are keenly aware of the very real challenges of this structure where prior authorizations delay care, utilization management strategies such as pre-payment and post-payment audits serve to trap providers in administrative wormholes.

“Providers need a comprehensive strategy that will mitigate risks and assess their readiness and ability to engage in these models," said Ted LeNeave, CEO and founder of Accura Healthcare of Iowa. Accura currently participates in Iowa's provider-owned integrated care network and is partnering with other local providers on an Institutional Special Needs Plan (I-SNP). If expanded opportunities arise within CMS' complementary specialist strategy, whether short or long term, LTC providers with some experience in value-based care and population health are positioned well to take a leadership role. “In the end, we risk being left behind if we do nothing," he said.

Nisha HammelIt behooves providers to take note and look at avenues through which they can lead and/or meaningfully participate in this evolving landscape. Forward-thinking providers are tackling these challenges head on by establishing I-SNPs or participating in ACOs or other care management models enabling them to strengthen their future position. The first step is learning more about these value based care models and the risks and opportunities that each present. The time is now.

Nisha Hammel is associate vice president, Population Health Management at the American Health Care Association.

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