McDermott Will & Emery Partner Ankur Goel moderated a panel during the Value-Based Care Symposium that focused on the risk-adjustment landscape and provided insights into how the regulatory environment and contractual partnerships may continue to shift in the coming years. The panelists shared their experiences navigating the current enforcement environment and the corresponding impact on value-based care and investment opportunities.

Session panelists included:

• Jeffrey De Los Reyes, Managing Director, Alvarez & Marsal, Healthcare Industry Group
• Wayne T. Gibson, Senior Managing Director, FTI Consulting
• Kanika Sabor, Managing Director, Healthcare Disputes and Economics, Ankura Consulting
• Timothy J. Wilder, FSA, MAAA, Principal and Consulting Actuary, Milliman

Top takeaways included:

1. Increased complexity of RADV audits. The methodologies for risk adjustment data validation (RADV) audits are more complex and have a broader reach than before, impacting how sampling is approached and how extrapolation is allocated back to providers by Medicare Advantage (MA) plans. The recent changes apply to US Centers for Medicare & Medicaid Services (CMS) and Department of Health and Human Services (HHS) Office of Inspector General (OIG) RADV audits, which means the potential financial risk is higher. Providers and Medicare Advantage organizations must analyze the potential impact of these changes and become better prepared to respond to these audits.
2. Greater collaboration between payors and providers. The changes brought about by the RADV audits will likely encourage more collaboration between payors and providers, as both parties will need to be more knowledgeable about what goes into their payments. Payors may also [...]
   
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In this session, McDermott Will & Emery Partner Patrick Healy moderated a panel that examined the expansion of value-based care in the employer market. We summarize the panel’s insights on how stakeholders can successfully implement value-based models in the employer market.

Session panelists included:

• Mark Miller, Chief Commercial Officer, Wildflower Health
• Simeon Niles, Vice President of Health Care Innovation, Morgan Health
• Carl Landry III, Director, Healthcare Strategy, Guidehouse

Top takeaways included:

1. Motivated by the unsustainable increase in healthcare spending and new consolidation and joint ventures among providers and health insurers, there is an accelerated need for solutions in the employer market. If the employer market does not self-regulate, the market fears that regulators will step in.
2. Regarding the relationship between employers with self-funded plans and third-party administrators (especially those owned by health insurers), there is confidence that third-party administrators’ historical relationships with employers will generate more turnkey programs producing easier-to-integrate value-based care models.
3. There is a particular emphasis on how smaller employers will utilize employee data and implement value-based care models in comparison to jumbo employers.
4. Significant interest in the jumbo-employer market is met with limited adoption and penetration of value-based care models when compared to the Medicare/Medicaid space. It is unclear whether these challenges are due to structural issues in the employer market limiting the pace of adoption. Such structural issues include employers as individual purchasers of coverage (as opposed to aggregate bulk purchasers); associated pools of covered lives too small for providers to take risk; [...]
   
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During this session, Mara McDermott, former Vice President, McDermott+Consulting, moderated a panel that discussed the current political and policymaking environment on Capitol Hill and what to watch for in 2023.

Session panelists included:

• Dr. Lauren Lyles-Stolz, Senior Director, Reimbursement, Innovation and Advocacy, National Association of Chain Drug Stores (NACDS)
• Aisha Pittman, Senior Vice President, Government Affairs, National Association of ACOs (NAACOS)
• Soumi Saha, Senior Vice President of Government Affairs, Premier Inc.
• Moderator: Mara McDermott, former Vice President, McDermott+Consulting

Top takeaways included:

1. Legislative and regulatory stakeholders have created a number of opportunities to engage in value-based care, including through the creation of the Center for Medicare and Medicaid Innovation (CMMI) and the Medicare Shared Savings Progam (MSSP). However, many of these initiatives have been—and continue to be—influenced by political and agency decision making. Therefore, educating members of Congress on why value is important remains a top priority.
2. Stakeholders are advocating for greater predictability and alignment across value-based initiatives. There are many competing interests in the system today, with Centers for Medicare & Medicaid Services (CMS) initiatives trending in different directions (e.g., Medicare Advantage versus MSSP). There are questions regarding how pharmacy services can better integrate into value-based care, how to engage specialists, how to sustain Medicare Advantage and more. Creating a pathway for all of these initiatives and stakeholders to coexist will be challenging, but could lead to greater value.
3. Better data is needed across programs. Faster, higher-quality data would allow CMS to more quickly cost-correct during the [...]
   
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During this session, Partner Jeremy Earl moderated a panel that collected insights on how specialists can participate in value-based care and the unique challenges specialists face in maximizing value-based care opportunities.

Session panelists included:

• Marissa Brittenham, Executive Vice President and Chief Strategy Officer, Surgery Partners
• David Dempsey, Chief Operating Officer, Heartbeat Health
• David Eagleton, Senior Vice President, Oncology Care Partners
• Josh Goldenberg, Group Vice President of Payor Partnerships, DaVita Inc.
• Moderator: Jeremy Earl, Partner, McDermott Will & Emery

Top takeaways included:

1. While some specialists are comfortable in the value-based care world, others have been slow to engage with and adopt value-based care initiatives. Convincing providers who have been paid on a fee-for-service basis their entire career to shift and take on risk can be challenging. These shifts can begin slowly, for example, by offering initial quality bonuses and then building up to longer-term strategies. However, the transition often involves a shift in mindset and can be challenging to accomplish at an organizational level.
2. Specialists may only have insight into a small portion of a patient’s life, so it can be hard to engage in the patient’s full care journey when specialists are not at the center of care. However, where specialists can provide a service for a fraction of the cost—for example, through site-of-care shifts—specialists can still have a large impact on costs and outcomes.
3. Different specialties are at different points in the value-based care transformation. The panelists representing ASCs and oncology, cardiology and dialysis providers, for [...]
   
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In this session, Erin Ney and Jason Slocum of Bain & Company provided data-driven insights on the current state of the value-based care industry. The session provided a look at the factors influencing provider adoption of risk-based adoption, the most promising investment opportunities in value-based care, and how likely the value-based care industry is to weather an economic downturn.

Top takeaways included:

1. Nearly 60% of healthcare payments in 2021 had at least some element tied to quality and value. However, the majority of these payments were upside risk, with less than 20% incorporating down-side risk. At the same time, nearly 40% of healthcare payments are not in value-based care models.
2. Around 80% of physicians surveyed are interested in participating in value-based care arrangements. However, that interest significantly decreases as the level of risk to the provider increases.
3. Providers continue to face financial, operational and administrative hurdles to adopting value-based care. Providers’ sense of preparedness across the financial, operational and administrative dimensions have decreased since 2017, with providers surveyed feeling less equipped to adopt and succeed in value-based care models.
4. To make providers more inclined to adopt value-based care, providers stated that they needed more sufficient financial resources, more effective coding and billing processes, and investments in additional staff to manage data, reporting and outreach. Similarly, providers reported they needed three key groups of enablers in order to transition from fee-for-service to risk-based models: (1) clinical care model enablers, (2) data and technology enablers, and (3) payor contracting enablers.
5. There [...]
   
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