Experts at HHS panel identify multi‑payer alignment, technical support to boost participation in total cost‑of‑care models

A panel convened by the U.S. Department of Health and Human Services heard wide agreement that multi‑payer alignment, faster payment timing and targeted technical assistance are key to expanding provider participation in population‑based total cost‑of‑care models.

Panelists — representing independent physician groups, health systems and rural providers — told the committee that organizational ownership and governance, the timing of payments, risk allocation in early performance years, and simplified program design determine whether an organization can join and succeed in risk‑bearing arrangements.

Dr. Christopher Crowe, chief executive officer and cofounder of Catalyst Health Group, said fundamental incentive design matters. “The fee for service ... is the devil of primary care,” Crowe said, arguing that prospective or subscription‑style primary‑care payments better support the longitudinal relationships needed to manage populations.

Chase Hammond, chief financial officer at Duly Health and Care, and other panelists stressed cash‑flow constraints for smaller physician groups. “If I’m gonna do the work now, but not get paid for 12 to 18 months,” Hammond said, the delay can make participation infeasible for independent practices that rely on regular fee‑for‑service revenue.

Jessica Walrad, vice president of finance for value‑based contracting and performance at Northwestern Medicine, described how program design details shape feasibility. Citing the Oncology Care Model, Walrad said Northwestern’s internal analysis showed “we did not see a clinically feasible path, to savings in this program” because inpatient costs in some episodes exceed potential target reductions even if all avoidable stays were eliminated. She emphasized that attribution methodology — whether patients are attributed at the tax‑identification number (TIN) level or at the TIN+NPI level — can materially change whether a provider’s attributed panel reflects its primary‑care population.

Brock Slebach, chief operating officer at the National Rural Health Association, outlined rural providers’ special challenges: thin margins, limited leadership bench strength, low patient volumes, and a pattern of short‑lived demonstrations that leave participants without a durable path forward. He said about 1,360 critical access hospitals exist nationwide and reported that roughly 47% of those hospitals participate in some form of accountable care organization, while many rural hospitals operate on thin or negative margins and face closure risks. Slebach and others urged models tailored to low‑volume settings and noted that multi‑payer approaches — including Medicaid and commercial participation alongside Medicare — make global or community budgets more viable.

Michael Barbati, vice president of government programs at Advocate Health, described organizational scale and multi‑state footprint as both enabling and complicating factors. Advocate reported substantial experience in value‑based contracts: “we generated almost 3 quarters of a billion dollars in taxpayer savings across a variety of models dating back to 2015,” Barbati said, and noted the system manages millions of covered lives across Medicare, Medicaid and commercial arrangements. He and other panelists described nested specialty arrangements (for example, carved‑out kidney or oncology pathways aligned with an ACO) as promising ways to pair specialty care with total‑cost‑of‑care incentives.

Panelists identified several recurring, actionable themes: - Multi‑payer alignment: Panelists repeatedly recommended aligning incentives across Medicare, Medicaid and commercial payers — or using global budgets that pool dollars across payers — to reduce conflicting signals and make population‑level financing predictable for providers. - Faster, more certain payments: Multiple speakers said long lags between performance and shared‑savings payment are a practical barrier for independent practices; bridging cash‑flow timing was described as a prerequisite for many groups’ participation. - Technical assistance and longer lead times: Rural and smaller providers need hands‑on technical assistance, analytic support and longer implementation lead times to evaluate and operationalize participation, panelists said. Panelists pointed to the burden of complex applications and the need for dedicated support to assess risk and resources required to join models. - Program design details: Attribution rules, risk‑adjustment methods, carve‑outs, episode definitions and the scope of allowable waivers (for services such as transportation or non‑medical supports) all affect whether a clinically feasible path to savings exists for a given provider mix. - Local, tailored models for rural communities: Several panelists highlighted the Pennsylvania rural health global‑budget demonstration as an example that preserved rural hospital operations while requiring transformation planning, and urged models that recognize low volume and thin margins in many rural settings. - Data interoperability and standardized metrics: Panelists called for common measure sets, risk‑adjustment approaches and shared data constructs across payers to reduce administrative burden.

Panelists also discussed operational examples. Advocate described a nested nephrology model that established a three‑year baseline for a 3,000‑member panel and reported earlier reductions in readmissions and increased transplant activity after shared investment in care management. Panelists offered contrasting examples where episode or oncology models failed to show a “clinically feasible path” to savings because inpatient costs dominate the episode price even when avoidable stays are minimized.

Committee members and panelists agreed there is no single silver bullet. Suggestions ranged from modest changes — such as TIN+NPI attribution and longer lead times for new model launches — to broader reforms, including national‑level investments in infrastructure analogous to past federal programs that accelerated electronic health record adoption. Panelists also emphasized that distribution of shared savings to frontline clinicians should be clear and timely and that team‑based payment approaches should include advanced practice providers and care teams, not just physicians.

The panel did not take formal votes. The session concluded with the committee adjourning for a lunch break and planning follow‑up listening sessions on implementation barriers and organization‑level supports.