Debbie Stadtler: [00:00:00] The transition from fee-for-service to value-based care is here. Learn the latest on new CMS payment models in this episode of Perspectives in Long Term Care.
Hi, I'm Debbie Stadtler, editor-in-chief of Provider magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living.
I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession. My guest today is Nisha Hammel, vice president of reimbursement policy and population health for AHCA and NCAL.
She leads the association's policy and strategic initiatives on value-based care and innovative payment models. She brings 20 years of experience in post-acute care and senior living. Welcome, Nisha. Thanks for being with [00:01:00] us.
Nisha Hammel: Thanks, Debbie. Thank you for having me.
Debbie Stadtler: We'd like to start at the beginning, so tell us a little bit about you and your career journey.
What led you to get started in long term care?
Nisha Hammel: My career journey really began next door with my maternal grandparents who were like second parents to me. I grew up in a home and culture that really revered old adults, so my passion for aging was shaped early. You could say, I honestly never stood a chance of choosing anything else.
Even when my peers would ask like, what are you majoring in? I stuck with geriatric social work as my master's program back when only a couple of schools in the entire country offered it as even as an optional major. From there, I started out as a social worker in a skilled nursing facility and moved [00:02:00] through a variety of operational and leadership roles in assisted living, home health, hospice, affordable housing.
Really, I think each step taught me something new about caring for older adults with dignity. I really feel very blessed for that incredible journey. Eventually, I joined a state association where I helped lead providers in exploring new ways to work together that included some of our earliest conversations around value-based care and population health, and even how long term care could participate in Medicare Advantage in a meaningful way.
It was an experience I still consider a privilege, and it has carried me into essentially the next chapter of my journey, which led me to AHCA, where I now have the opportunity to help advance models and policies that [00:03:00] transform care for older adults and support the truly exceptional providers who care for them every single day.
Also, having the opportunity to advocate for some common sense policies to Medicare Advantage. I'd say each position has really felt like something I was called to do, and I am deeply humbled by this path and incredibly grateful that it all started with two grandparents right next door.
Debbie Stadtler: I'm always amazed at how many people have that personal connection, whether it's a grandparent or a family friend or a mother/father that really started them out in this profession.
And I think, like you said, so many people feel it's a calling. It's really such a personal connection to this work, and I think that makes it really special. I want us to talk about value-based payments. Set the stage for us. [00:04:00] Where are we now? What has happened recently? What's going on in this area?
Nisha Hammel: Sure.
I'd say value-based care has consistently received support from both Democratic and Republican administrations. While each may emphasize different elements, I think the overall commitment to achieving better quality and outcomes for every dollar spent has remained steady. What's happening now is that value-based care has accelerated pretty significantly in the last several years, and especially I think with this administration, it has been very highly active releasing or finalizing numerous models.
In the last year, going to this year, there's been about 11 models. Wow. Which, yes, which aligns with broader CMS movement to test, expand, or retire models, all with the [00:05:00] goal of improving outcomes and containing costs. So if we think about some of the pieces that may be slightly different in this administration, along with kind of let's say the cost-cutting, improving quality outcomes, patient experience, there's also been a strong shift towards prevention.
Also a greater focus on provider risk and accountability. So there's greater attention to having providers have some skin in the game. So not only upside, but also some downside risk. Technology enabled care is becoming much more central and there is a growing focus on the facts and benefits. Individuals are important partners in care.
And so the growing focus on patient engagement, you've seen that become much [00:06:00] more key in recent CMS models.
Sometimes there's a sense of Medicare Advantage and just thinking about Medicare Advantage and then pure fee-for-service. But if we think about what's happening today, you've really got more than 70% of payments that are now linked to patient experience and quality outcomes in some way. And that's, I think, an important statistic that's that we may not often think about.
Debbie Stadtler: I think that's a surprising statistic. I would not have guessed that it was that high, but it just clearly shows why the value-based care and the population health area is so important for providers right now. What do long term care and assisted living providers need to know? You mentioned 11 new models that have just come out within [00:07:00] the past year.
Do all the models apply to them? What do they need to know at this point in time?
Nisha Hammel: That's a great question. In the effort of CMS to redesign and look at things differently, there are certain models that apply more directly and there are models that are a little bit more adjacent, but helpful for long term care providers to track because.
The models, and I'd say the developments are important to monitor and understand because they could affect referral patterns. For example, care coordination expectations, and financial relationships.
Debbie Stadtler: Tell us more about the models that apply to long term care providers. I know there are several.
Nisha Hammel: So let's just start with the first model, which is TEAMs.
And TEAMs is a mandatory model. So the other thing you'll notice with this administration, they've launched a [00:08:00] few more mandatory models. So TEAMs is a mandatory episodic payment model that really holds hospitals in certain core based statistical areas accountable for the cost of care for an episode that essentially begins with the anchor hospitalization of the procedure.
And follows about 30 days post discharge for five. CMS considers high volume, high cost surgical conditions, and long term care providers and assisted living providers can often play a major role in patient recovery. And if you think about hospitals need strong post-acute care partners to help reduce readmission and ensure coordinated transition.
This makes facilities part of the ecosystem of this model. Like I said, important to note though the good news is that AHCA has a [00:09:00] toolkit and resources and data available for providers to understand. Does it impact me, first of all, am I one of those facilities there are in those CBSA, right? And then be able to look at data through Trend Tracker that enables them to understand scope, impact and be able to make more informed choices about the path that they may want to go down.
Debbie Stadtler: That's a good introduction to TEAMs. What's the next model we need to know more about?
Nisha Hammel: The second model that I'd like to call out is the AHEAD model, which is the achieving health care efficiency through accountable design.
And the uniqueness about this model is that it is a state level model. It was introduced under Biden administration and finalized by the Trump administration, and it is a voluntary state total cost of [00:10:00] care model, which started with Maryland. Starting this year in 2026 and is extended all the way to 2035, and you've got three different cohorts and participating states.
You've got Maryland, Connecticut, Hawaii, and Vermont as cohort two, and then Rhode Island and Downstate New York, certain downstate, New York counties, I should say in cohort three. And some of the kind of key features of these is that states can receive up to $12 million to build infrastructure to help design the program.
It includes hospital global budgets and like primary care, capitation, lag payments. So again, it's important to pay attention to the fact that it's certain states, but I think what is noteworthy in this is as part of [00:11:00] the states, CMS has also introduced Geo AHEAD, which is a AHEAD and a model, which essentially passively aligns any beneficiary that's not aligned to participating in another ACO program or Medicare advantage, or is in, for example, into the Geo AHEAD. And I think that's striking, and that's something different that I think providers participating in these regions need to be aware of because it will certainly automatically align these residents to ACO structures, and thus there could be corresponding care expectations.
Debbie Stadtler: So AHEAD applies only to certain states, and Geo AHEAD is different. Is there another model we need to know about?
Nisha Hammel: The next one that we'll go to is LEAD. And LEAD [00:12:00] is the long term enhanced ACO design. And I think providers should really pay attention to this one. It is a new 10 year accountable care model set to replace ACO REACH.
It's emphasizing stronger alignment, continues to focus on high need and complex populations, but it's also looking to engage providers that have not maybe previously participated in models, so safety net providers, rural providers. The model also includes CARA, which is CMS Administered Risk Arrangements, which essentially enables what's called like a shadow bundle pricing within ACOs, which may be an opportunity for long term care providers to collaborate in specialty and chronic care episodes.
This is on the short-term care side, for example. So [00:13:00] we do see broader participation opportunities for providers. We're expecting the RFA pretty soon, and so something for our providers to track something provided that AHCA is tracking very closely. And we have provided some recommendations to CMS in a recently released LTC focused ACO white paper that encourages CMS to recognize the value and the distinct population and setting, setting specific pieces that long term care providers bring and how they may think about engaging long term care providers. Slightly different in the LEAD model.
Debbie Stadtler: So LEAD focuses on high need and complex residents. What other models apply for long term care?
Nisha Hammel: Then a couple of other models I'll just call out, which I think is good to know about the ambulatory [00:14:00] specialty care model. It's a mandatory model targeting high volume, specialty conditions, starting with heart failure and low back pain, and the goal is to really improve outcomes and avoid or reduce avoidable hospitalization.
I know there's a ton of acronyms. But it would not be CMMI if it wasn't. All the acronyms are notable because it introduces prior authorization into fee-for-service for conditions that CMS notes are low value and at high risk for fraud, waste and abuse. One example being skin substitutes.
You've also got the ACCESS model, which promotes essentially tech enabled chronic care management. It's emphasizing the use of digital tools, remote monitoring, and AI driven support. I think what's interesting with this model is it's the first model that pays [00:15:00] for outcomes known as outcome aligned payments versus defined set of services or model parameters.
And then you've got MAHA ELEVATE, which is a model focused on chronic care and how lifestyle medicine can impact and moderate upstream drivers of health and like nonclinical supports and prevention. So I think a real opportunity for our assisted living providers to track and there've been, and then there are several other kind of drug pricing and pharmacy related models.
Debbie Stadtler: I think you make a really good point about how providers are not on their own with this. You mentioned that AHCA has toolkits, articles, things to help folks learn about all of these models, understand them, educate themselves. So while it seems like a lot of acronyms and a lot of new things coming out all [00:16:00] at once, and AHCA is really here to help folks get their hands around this and understand what they need to be doing or start doing.
Nisha Hammel: I think the beauty of the association and the fact that the association is supporting our members is that they have an objective resource. So if they're trying to figure this out, noodle it. There are a lot of partners and providers and vendors out there, and sometimes it may be difficult to sort through rhe noise or all the options, and I would encourage providers, that's what your association is here for and this is how we can support you.
Debbie Stadtler: Absolutely. What do providers need to know who are starting this value-based care journey? What do they need to know to prepare for this journey? What do you recommend as some of those beginning pieces?
Nisha Hammel: I [00:17:00] will probably sound like a broken record, but start by getting informed. Yes. If you don't already know about the models, explore it. Like we said, access some of the resources. Reach out. Attend AHCA’s Population Health Management Summit, which is the only conference of its type focused on long term care providers and assisted living providers meaningful participation in pop health. So I think this is, that's a fantastic, it's two days of the ability to get immersed, meet and network, meet some incredible folks that are doing some good things that have started that you've had some pioneers. So first of all, get informed. If you also don't already know, ask your physicians.
Ask the clinicians, your nurse practitioners for example, or physician's assistants that are coming into your building and seeing your residents. Whether they participate in an ACO or the value-based care arrangements. I talk to [00:18:00] providers around the country and they may assume that they're contracting with an independent provider, and until they ask the question, they aren't aware that the provider may, even if it's an independent prep provider, may be connected to an ACO.
And if they are, that means their beneficiaries are automatically part of that ACO. So get informed, ask questions. I would say understand your data. Know your baseline hospitalization rates, your emergency department utilization, your readmission rates. These metrics drive both quality and financial performance and value-based care.
Then get an understanding or essentially assess your clinical capabilities, right? Determine whether your clinicians have the competencies, the workflows needed to support proactive early intervention rather than defaulting to [00:19:00] hospital transfers, for example. And review policies and protocols. There are sometimes inadvertently policies and protocols can move people to hospitalizations or ED referrals, which may not be necessary, may not make sense.
Ensure you have structures in place that really empower teams to manage changes in condition on site whenever appropriate. It's so if something is unavoidable. You have to send a person out, but if it's avoidable, you want to make, be able to care for the person on side and then build, let's say internal alignment, engage leadership, nursing, medical staff early.
So the shift towards value-based care is deliberate and consistent with the organization's overall strategy and leadership and where you want to head and go.
Debbie Stadtler: We mentioned that [00:20:00] AHCA and NCAL provide resources, support, education on value-based care, but how else are they involved in this sort of transition to value-based care?
What is the association really advocating for in this space?
Nisha Hammel: Sure. AHCA is actively engaged and advocating on behalf of our members, and we are really advocating for value-based care models that reflect the true realities and the strengths of long term care settings rather than models designed for community-based populations.
We are urging policymakers to adopt frameworks, I referenced the LTC focused, ACO model, for example, that recognized nursing facilities and assisted living's really unique capabilities, including the 24-7 clinical oversight, the interdisciplinary care [00:21:00] teams, the onsite supports, the focus on social supports and the fact of food, three meals a day, plus snacks that provided transportation opportunities for active social engagement and the ability to manage these high need, high costs residents effectively.
So our global goal is to ensure, first that providers that want to be a risk-bearing entity have the opportunity to do that and have a pathway to do that. And for others that don't necessarily want to be the risk-bearing entity, but want to have meaningful ways to engage that reimbursement and regulatory structures can support them being able to effectively do so and support proactive timely care decisions made locally right in the settings where our residents live and where they call home. [00:22:00]
Debbie Stadtler: That makes a lot of sense. We really want to make sure that these models work well for AHCA and NCAL members, not the members having to squeeze themselves into models that are not quite set up for the specific populations and care that they give. So that makes a ton of sense.
So you mentioned a little bit earlier that this transition from fee-for-service, where you're really focused on services into being focused much more on outcomes is the hallmark of value-based care. How does this impact how we think about and measure quality? It really seems like it's almost a whole new idea on how we do that.
Nisha Hammel: The quality and outcomes is really at the heart of every value-based care model.
Debbie Stadtler: Yes.
Nisha Hammel: The challenge is that each model comes with its own set of quality measures. And those measures don't [00:23:00] always align well with the long term care population. Like I said, most of the models are designed for a community dwelling population, so that misalignment can create real barriers for nursing home and assisted living communities.
However, I'd say there are some core quality outcomes that are important no matter. Who the payer is, what the model is, and whether it's not directly a quality measure. What you do to drive towards that has impact? So for our older adult population, let's say three of the most meaningful indicators are reducing avoidable hospitalization, minimizing unnecessary emergency department visits, and reducing inappropriate readmission rates, right?
Because we know that when we keep our residents stable and cared for in place, that's better for their health. As a family member that's cared for a loved one, it [00:24:00] certainly makes a difference to my mental health and my kind of overall support, their experience and the overall system.
Debbie Stadtler: That makes sense.
Quality is obviously our North Star and to really be honing in on those quality measures that we know and we monitor and we keep tabs of every day: reducing the hospitalizations. That's what we know how to do. And so it's really great that this, even though it's a transition and some new things to learn, there's really still that focus on quality and we know what that looks like and how to do that well.
Nisha Hammel: That's exactly right.
Debbie Stadtler: What do you want listeners to take away from this? There's a lot to learn, a lot to know. What's your sort of bottom line takeaway right now?
Nisha Hammel: The most important takeaway is to be informed. Providers may ultimately decide [00:25:00] not to participate.
Absolutely. Their choice. It should be a conscious decision, not a surprise. I'd say while the growing number of models can truly feel daunting and having been a provider, it seems very overwhelming. It also presents an opportunity by offering maybe more pathways that weren't there previously to participate.
So there could be different points of entry and different ways to engage all not requiring providers to assume significant amount of risks, which understandably is not for everyone. We also know if we think about assisted living communities, there's a huge spectrum between providers that are more focused on the social model versus more of a health care model.
So really being very cognizant that many providers don't also [00:26:00] realize that their residents are already in ACOs. So where they are already helping manage, care and improve outcomes, they're just doing so without capturing the value that they're creating. And so stay informed, get educated, ask questions.
Utilize your resources. Please call me. Please call my colleague Rohini, and we are here to help.
Debbie Stadtler: I love that. Make sure you are informed and AHCA/NCAL is here to help you with that. I think that's just the greatest note to close on. Thank you again for joining us, Nisha. This has been a great discussion.
Nisha Hammel: Thank you so much, Debbie. Appreciate the opportunity.
Debbie Stadtler: Visit the
AHCA/NCAL website or
providermagazine.com to learn more about value-based care and payment models and the Population Health Management Summit. And thanks to everyone for [00:27:00] listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession.
And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.