4.19.2023 Board Book

1 represents traditional, fee-for-service payment and Categories 2-4 represent alter native payment models (APMs). Category 2 is designed around incentivizing providers by offering bonus payments based on investments in supportive data collection and analysis, or for meeting quality benchmarks. (Investments in adapting electronic health records to facilitate obesity diagnosis, monitoring and reporting might be one such set of investments.) Category 3 puts provider payments at risk, either upside-only risk (pro viders share in savings from efficient care), or two-sided-risk (providers share in savings or losses). Category 4 APMs are entirely population-based; providers are paid a fixed amount (such as a defined per-patient/per-month, PMPM payment) for every patient attributed to the provider. Payment under every APM (Categories 2-3-4) is regulated in the sense that providers must demonstrate that the care they deliver meets specific performance or quality benchmarks as defined in quality metrics the providers must report to the payer. The HCP-LAN framework is useful for envisioning payment strategies for obesity treat ment and support, not least because it is a reference point for multiple payers, includ ing large national insurers such as United Health Group, Elevance/Anthem, Cigna, CVS/ Aetna, and Humana. Two attributes of the framework also suggest points that are im portant for envisioning obesity treatment and support payment models: Metrics: • Patient outcome and care quality metrics play the role of regulating providers and the services they delivery by ensuring that care is delivered according to guide line-based standards. Clinical practice guidelines and expert consensus on obesity treatment and care have shifted markedly in recent years towards more active treatment of obesity at earlier stages of progression (i.e. before patients develop obesity-related complications and co-morbid diseases.) Guidelines support more assertive treatment, not only with non-medication interventions (such as Intensive Behavioral Therapy) and anti-obesity medications, but surgery as well. xxxii • Development and validation of obesity-related metrics will be essential for the development of alternative payment models for obesity treatment and support and should spark close collaboration among stakeholder groups, including measure development organizations such as the NCQA, PQA and the National Quality Forum. xxxiii Validation of population-level metrics will also be an opportunity to incor porate measures that track and promote active interventions to close racial-ethnic

24

Envisioning Value-based Provider Payment for Obesity Treatment and Support