The Rise and End of MA-VBID: Lessons from Medicare Advantage’s Value-Based Insurance Experiment for LTSS

Each of the seven CMMI models we explored brought valuable insights into how value-based care can improve outcomes and reduce costs. While not specifically designed for LTSS, many offered lessons that could help shape more person-centered, integrated approaches in that space.

Maryland Total Cost of Care (TCOC) Model: The Maryland TCOC Model delivered sustained Medicare savings, driven by global hospital budgets and primary care transformation. Its state-level governance and equity metrics made it one of the most comprehensive models to date. For LTSS, the biggest takeaway is the power of aligning financial incentives with population-level accountability. Its infrastructure offers a strong foundation for integrated care, especially if future iterations include non-medical supports.

Pioneer ACO Model: One of the earliest tests of population-based payment, Pioneer ACOs reduced spending and improved quality through care coordination and shared financial risk. The model’s flexibility and innovation made it a springboard for later ACO programs. Its emphasis on managing high-risk patients and aligning incentives could support HCBS providers in reducing institutionalization and improving transitions of care.

Accountable Health Communities (AHC) Model: While AHC did not yield major cost savings, it transformed how the health system thinks about social needs. The Assistance Track, which paired screening with navigation, reduced emergency visits and avoidable hospital use. For LTSS, AHC underscores the importance of integrating social supports into care delivery and the necessity of sustained investment in navigation, data sharing, and community partnerships.

Bundled Payments for Care Improvement Advanced (BPCI-A): BPCI-A generated over $800 million in net savings for Medicare, largely by reducing unnecessary post-acute care. Physician group practices outperformed hospitals by redesigning care around transitions and recovery. For LTSS, the model illustrates how episodic payments can incentivize home-based care, though adaptations would be needed to account for functional status, caregiver needs, and social supports.

Home Health Value-Based Purchasing (HHVBP): The HHVBP model improved care quality, reduced hospitalizations, and saved Medicare nearly $950 million across nine states. Small and rural agencies performed as well as larger ones, proving scalability. For LTSS, the model demonstrates how quality-linked payments can work when paired with actionable data, timely feedback, and support for improvement, even in fragmented or home-based delivery settings.

Medicare Advantage Value-Based Insurance Design (MA-VBID): MA-VBID empowered plans to personalize benefits based on chronic conditions and social needs, leading to greater use of services like meals, transportation, and caregiver support. However, costs outpaced savings, and structural issues in Medicare Advantage limited impact. For LTSS populations, the model shows the importance of customizing benefits for dual eligibles, but also the need for stronger guardrails, equity metrics, and financial accountability.