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PTAC PCDT urges tailored participation pathways, cites revenue share and data sharing as main barriers to population-based total cost-of-care models
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Summary
A PTAC preliminary comment development team presentation summarized evidence that CMMI and MSSP produced savings but participation has plateaued; the group proposed developing ‘participation pathways’ that account for organizational business models, market factors and data-sharing to grow value-based care participation.
The Physician-Focused Payment Model Technical Advisory Committee (PTAC) heard a data-driven presentation Wednesday on barriers to participation in population-based total cost-of-care models and ideas to support primary and specialty care transformation.
PTAC co-chair Lee Mills, Chief Medical Officer of Aetna Better Health of Oklahoma, opened the meeting and reviewed logistics and how the committee will use public comments and background materials posted on the ASPE PTAC website to inform a report to the Secretary of the U.S. Department of Health and Human Services. Jim Walton, a PTAC member and lead of the Preliminary Comment Development Team (PCDT), presented the PCDT’s findings and a draft framework for “participation pathways.”
The PCDT presentation summarized ASPE’s review of the first decade of Medicare alternative payment model work. It reported that CMMI models generated estimated gross savings of roughly $7 billion to $11 billion and that the Medicare Shared Savings Program (MSSP) produced roughly $23 billion to $31 billion in savings over the 2012–2022 period cited by ASPE. The PCDT noted those impacts were concentrated in counties with high penetration and participation.
The team described three related, high-level trends since 2010: covered lives and number of ACOs plateaued (roughly 36 million covered lives and about 900–1,000 ACOs by 2021); hospital and integrated delivery system (IDS) leadership of ACOs declined while physician‑led ACOs grew; and specialty clinicians continue to participate at lower rates than primary care. The PCDT noted low market penetration of Medicare Advanced APMs — cited examples showed roughly 6% physician penetration and about 28% hospital/IDS penetration — and said that leaves substantial untapped opportunity.
To explain uneven participation, the PCDT proposed grouping organizations into “participation pathways” based on four organizational characteristic areas: (1) ownership/organizational type (physician‑owned, hospital/IDS, payer‑affiliated), (2) internal organizational characteristics (governance, clinical integration, EHR consolidation), (3) market characteristics (urban/rural, area deprivation, Medicare Advantage penetration), and (4) business model/revenue characteristics (total annual revenue, revenue mix, and revenue of participating ACO entities as a share of total spending for assigned beneficiaries). The team argued that business-model features — in particular the share of an organization’s revenue that is at risk under an APM — strongly influence whether an organization will enter and remain in value‑based contracts.
The PCDT outlined how pathways could be used to tailor benchmark rules, risk arrangements, and performance measures to groups of like organizations so participation and administrative complexity are better aligned with organizational capacity. The team also proposed additional policy options to improve the competitiveness of population‑based total cost‑of‑care models, including adjustments that address market consolidation, low‑penetration markets, Medicare Advantage mix, waiver incentives, beneficiary engagement incentives and nested specialty‑episode incentives.
On specialty participation the team highlighted two design ideas: (1) nested specialty total cost episodes for lower‑variation specialty services (for example, certain gastroenterology procedures) that sit inside broader population models; and (2) condition‑based specialty bundles nested under population models to encourage collaboration between primary care and specialists. The presentation flagged health‑information sharing, varied EHR platforms and the presence of specialty networks not on a system EHR as recurring operational barriers.
PCDT members and PTAC participants emphasized that a persistent barrier is the continued financial attractiveness of fee‑for‑service for many organizations. The committee’s discussion returned repeatedly to the point that, while APMs and MSSP have produced measurable savings and quality improvements, a sizable portion of providers can still operate profitably under fee‑for‑service and therefore face little economic imperative to shift into population‑based models.
The PCDT recommended that PTAC use the meeting and public comment to refine concrete pathway definitions, identify where benchmarks and risk rules could be adapted to pathway groupings, and explore which policy levers (including those built into current APM architectures) could be used to increase the share of revenue organizations place at risk when appropriate. PTAC members said next steps should prioritize (a) clarifying which organizations belong in each pathway, (b) identifying minimum data and operational requirements for participation, and (c) assessing how to preserve flexibility while avoiding undue administrative complexity for both participants and CMS.
The committee scheduled additional panels and public comment sessions over the next two days; the PCDT will use the meeting record and public input to inform PTAC’s report to the Secretary of HHS.
