Health care in the US is moving towards value-based care. The Center for Medicare and Medicaid Innovation (CMMI) continues to develop a growing portfolio and testing various payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through improvement of the healthcare system.

This presentation highlights drivers of value-based care by highlighting Medicare spending on older adults, in general, and on chronic disease and multiple co-morbidities, in particular.

By 2030, all baby boomers will reach the age of 65, raising the number of older adults to 77M by 2034. Medicare spent more than $7B as of 2017 and is projected to reach unsustainable expenditures of $6T in 2027. 17% of Medicare beneficiaries account for 53% of spending and 81% of hospital readmission according to a 2017 Medicare data. The Lewin Group (2010) reports the cost of care for individuals with both chronic condition and functional limitations are double those with chronic conditions alone.
Furthermore, this presentation shows Medicare fee-for-service (FFS) payment reforms as relates to technology, value-based care, cost, and value.

Medicare value-based programs include end-stage renal disease quality incentive program (ESRD QIP), hospital value-based purchasing program (VBP), hospital readmission reduction program (HRRP), value modifier (VM), and hospital-acquired conditions (HAC) reduction program (HAC), skilled nursing facility value-based program (SNFVBP), home health value-based program (HHVBP), among others.

Focus on the details and resources is given to the forthcoming 2021 CMMI program that affects FFS practices, including home-based primary care (HBPC) practices: primary care first (PCF) and seriously ill population (SIP).

Practices will be able to participate in one of three PCF components: PCF-general, SIP, and hybrid PCF+SIP. PCF-general is for advanced primary care practices and assumes the financial risk in exchange for reduced administrative burden and performance-based payments. The SIP component promotes care for high-need, seriously ill population for those who lack a primary care practitioner or effective care coordination. CMS uses claims data to identify beneficiaries who meet the requirements.