Where value-based payment is headed during the second Trump administration

Like much of federal healthcare policy in the next few years, the push to improve value-based payment and accountable care figures to be influenced by two distinctive aspects of the Trump administration: MAHA and DOGE.

MAHA is Make America Healthy Again, the movement championed by new HHS Secretary Robert F. Kennedy Jr., while DOGE is the Department of Government Efficiency, an initiative overseen by Elon Musk to streamline the federal government.

Kennedy, for example, has said his priority is to improve the nation’s health by curbing chronic disease. Value-based payment likely will be central to that effort. It remains to be seen whether he and HHS look to continue with the Biden administration’s goal of getting all Traditional Medicare beneficiaries into an accountable care relationship by 2030.

“The whole point of accountable care has been to make care more coordinated and prevention-oriented, but this seems like a further push in the direction of preventing illnesses, preventing chronic diseases,” said Mark McClellan, MD, PhD, director of the Duke-Margolis Institute for Health Policy. “And then also a desire to make healthcare simpler for people.”

In a session Feb. 24 at the Fourth Virtual Value-based Payment Summit, McClellan was joined by Adam Boehler, the current U.S. Envoy for Hostages and CEO of the healthcare investment firm Rubicon Founders, and formerly director of the Center for Medicare & Medicaid Innovation (CMMI) for part of President Donald Trump’s first term; and Elizabeth Fowler, JD, PhD, director of CMMI during the Biden administration.

Ramping up prevention

Boehler acknowledged controversy over Kennedy’s stance on vaccines but said “the MAHA idea of Americans seeing ingredients and eating healthy is one that really hits with people.”

“If [consumers] are focused and incented and we have the right health [policies] for them, then you are going to reduce healthcare costs,” he added.

CMMI under both the first Trump administration and the Biden administration promoted the Accountable Health Communities Model, in which participants were required to screen for health-related social needs and offer referrals to community resources and other social services.

In the broader Medicare program, conducting social determinants of health (SDoH) risk assessments was reimbursable for physicians starting in 2024. Reimbursement also expanded to include health integration services furnished by auxiliary personnel such as community health workers.

“We know that nonmedical drivers of health have played a really important role in keeping people healthy, in addressing areas of need that really do contribute to better health,” said Fowler, who received HFMA’s Richard L. Clarke Board of Directors Award in 2024. “I’m hoping that as we move down this Making America Healthy pathway, that that is recognized and that we continue to embrace and promote those approaches to thinking about healthcare.”

A focused approach to developing prevention-oriented policies is vital in value-based payment efforts, McClellan said.

“What’s going to be critical is being able to identify some clear steps,” he said. “It may not be comprehensive, it may not be for everybody, but maybe some new programs for people who have nutritional or other barriers to care that are leading to untreated or more complex chronic diseases — something [such as] an app, more convenient digital care.”

Lean times

Another key component in the current administration is DOGE and its influence on federal agencies in the effort to reduce administrative costs and pare the size of the government.

A direct route to achieving those goals is reductions in personnel, with HHS reportedly having shed 5,000 jobs across its agencies and being told to cut more positions (similar plans across departments are being challenged in court).

But there also are ways CMMI can make payment models more efficient, with implications for value-based payment and accountable care, the panelists said.

Improving the dissemination of data analytics would help participating providers and could be a way to save substantially on contractor costs, Boehler said. The effort may gain momentum in Medicare under Chris Klomp, whom Dr. Mehmet Oz has tapped to direct the program assuming Oz is confirmed as CMS administrator. Klomp has a technology background as former CEO of the care coordination platform Collective Medical.

Medicare data dispersed to participants in the Medicare Shared Savings Program (MSSP) and the ACO REACH Model generally is superior and timelier compared with data distributed to providers by commercial health plans, Boehler said. But there is room for progress.

“We can get it even quicker, and it would be very easy,” Boehler said. “One of the things is to put an AI tool even on the CMS data to allow small providers to play around with it. These are very inexpensive things, especially on a CMS scale.

“You can see some real ability for some real great predictors, for some real great information around how much more in claims you’re supposed to get [over a given period], different seasonal trends.”

Creating stakes for consumers

Accountable care models would benefit from greater patient buy-in, Boehler said, meaning there’s merit in expanding shared savings to include patients.

Allowing patients to reap savings from healthy choices that affect healthcare costs “can make a big difference, and it will be the difference between people understanding the ACO or accountable care, any of these things,” Boehler said. “If you have people getting checks and seeing that making a difference in their life, that’s a big deal, and that makes it a joint proposition between the healthcare system and the person.”

Another way to make the concept resonate with patients is to think about the terminology used in consumer engagement, Fowler said. She noted that the term value-based care “turns people off sometimes.”

Policymakers should be “really trying to think about how we talk about what we’re trying to achieve, which is team-based, patient-centered care,” she said. “This is really about putting the patient first and thinking about it from the patient’s perspective. This is the care that we want for our own patients, for our own parents, for our relatives.”

McClellan hopes to see better incorporation of specialties in accountable care models, including in ways that make specialists more easily accessible to patients in longitudinal care scenarios.

Ideally, accountable care beneficiaries would have access to digital modes of care, including apps, McClellan said, and be guided toward “less costly steps to manage that condition where they might need a consultation with a specialist but don’t need a full-fledged referral. And [you] certainly want to avoid those downstream costly procedures.”