Alternative Payment Models: Medicare

The Centers for Medicare & Medicaid Services (CMS) has taken the lead in testing voluntary and mandatory value-based care programs with physicians, hospitals, health plans, and others. 

CMS aims to have all Medicare and most Medicaid beneficiaries enrolled in accountable care programs by 2030. The agency also is committed to promoting health equity through these initiatives by including an equity component in all new programs and revising existing programs to encourage participation by those serving disadvantaged or rural populations. The following is a list of value-based care programs available in Texas:  

Medicare Shared Savings Program (MSSP)
MSSP accountable care organizations (ACOs) are groups of physicians, hospitals, and other health care providers who collaborate to give coordinated high-quality care to traditional Medicare beneficiaries. When an ACO meets quality and cost benchmarks, it may be eligible to share in the savings it achieves for the Medicare program. Several participation tracks are available depending on the ACO’s experience and desire to take on financial risk, where penalties are in place if the group does not achieve historical cost benchmarks.

ACO Realizing Equity, Access, and Community Health (ACO Reach)
The ACO REACH model promotes health equity and focuses on bringing the benefits of accountable care to traditional Medicare beneficiaries in underserved communities. All model participants must develop a health equity plan to identify underserved communities and implement initiatives to reduce health disparities within their beneficiary populations. Care is provided through ACOs paid under one of two options: (1) the Professional track, which offers primary care capitation – a risk-adjusted monthly payment for primary care services; or (2) the Global track, which offers primary care capitation or total care capitation – a risk-adjusted monthly payment for all covered services, including specialty care.  

Bundled Payments for Care Improvement Advanced (BPCI Advanced)
The BPCI Advanced model aims to encourage clinicians to redesign care delivery by adopting best practices, reducing variation from standards of care, and providing a clinically appropriate level of services for patients throughout a 90-day clinical episode duration.

Comprehensive Care for Joint Replacement Model (CJR)
The Comprehensive Care for Joint Replacement (CJR) Model is designed to improve care for Medicare patients undergoing hip and knee replacements (also called lower extremity joint replacements or LEJR) performed in the inpatient or outpatient setting and for total ankle replacements performed in the inpatient setting. 

Enhancing Oncology Model (EOM)
The EOM aims to drive transformation and improve care coordination in oncology by preserving and enhancing the quality of care furnished to beneficiaries undergoing treatment for cancer while reducing program spending under Medicare fee-for-service. Under EOM, participating oncology practices take on financial and performance accountability for episodes of care surrounding systemic chemotherapy administration to patients with common cancer types.

ESRD Treatment Choices (ETC)
The ETC model is intended to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD), while reducing Medicare expenditures and preserving or enhancing the quality of care furnished to beneficiaries with ESRD. The model provides additional support to those who treat underserved patients, including patients who are dually eligible for Medicare and Medicaid, as well as Medicare beneficiaries who are eligible to receive low-income subsidies for prescription drug costs through the Medicare Part D program.

Kidney Care Choices (KCC)
In the KCC model, nephrologists, dialysis facilities, and other health care providers form accountable care organizations to manage care for beneficiaries with late-stage chronic kidney disease, end stage renal disease, or a kidney transplant.

Last Updated On

September 22, 2023

Originally Published On

September 22, 2023