Early Results From CMMI’s Rapid Cycle Innovation Program

A Feb. 19 webinar offered early insights from participants in the CMS Innovation Center’s Rapid Cycle Innovation Program (RCIP), in which CMS is partnering with alternative payment model participants to administer rapid randomized controlled trials (RRCTs) that focus on real health outcomes.

As CMS explained when the initiative was launched last November, the first two Rapid Cycle Innovation Program tests include participants from the ACO REACH and Kidney Care Choices models to answer two questions, insights from which will help providers across the care continuum engage patients and families more effectively, support prevention, and reduce chronic disease: How can providers change patient outreach to improve receipt of preventive care? and How can providers improve patient follow-up after discharge to keep patients from having to return to the hospital?

On Feb. 19, the Duke-Margolis Institute for Health Policy featured a panel discussion with an RCIP participant, Manish Tanna, M.D., president of Nephrology Associates of Northern Illinois and Indiana, and Andrea West, M.P.H, a health insurance specialist at the CMS Innovation Center, also known as the Center for Medicare & Medicaid Innovation, or CMMI. 
West started off by saying that CMMI is uniquely positioned to quickly scale what can help improve success in alternative payment models. “But the on-the-ground actions that our participants take vary pretty widely,” she added, “so it's hard for us in our more summative and traditional program evaluations to capture and quickly scale what is working, what are those tactical, on-the-ground actions that are driving lower costs, and higher quality care.”

She noted that rapid randomized control trials have emerged as a way to apply the gold standard of evidence generation very rapidly, generating findings in a matter of months, rather than years. In most cases, they can focus on tactical changes and can be minimally disruptive to workflows, West added. She mentioned the work being done at NYU Langone’s Rapid Randomized Controlled Trial (RCT) Lab, led by Leora Horwitz, M.D., M.H.S., which Healthcare Innovation wrote about in 2020. 

CMMI decided to support current innovation model participants who volunteer to design and conduct their own rapid RCTs. Besides identifying and rapidly scaling what works, CMMI also wants “to help build the capacity and the willingness within participant organizations to conduct rapid RCTs on their own in the future, and tell their peers about it, because we do really think that this is a useful tool to drive rapid improvement, rapid learning,” West said. 

The first test that looked at whether changes in patient outreach improve care receipt and preventive care. The second test looked at whether changes in patient outreach after a discharge from a hospital improves follow-up care receipt or readmission. CMMI will share more about the work in the coming months.

Evidence that can be used in real time

Tanna said Nephrology Associates of Northern Illinois and Indiana was interested in this program because its leaders wanted outcome evidence that they could actually use in real time while the work was happening. “When we deal with different programs, initiatives, and interventions, we often learn lessons a year or a year and a half after the fact. What attracted us to the RCIP was the ability to work with a team that would help us design a project that we could learn from in real time.”

“We wanted to study different outreach approaches to better understand what drives meaningful preventive care in our high-risk CKD [chronic kidney disease] population.” 

Tanna said they were able to randomize 810 patients in 16 locations. The control group was encouraged to have appointments within six months, and the intervention group was encouraged to have earlier appointments, either seven days, 14 days or 21 days. The analysis was done by regression and controlled for clustering by site, as well as for demographic variables like age and gender and race.

“What we found is that specific MyChart, messaging was effective in engaging patients to schedule earlier appointments, most notably in the 21-day mark. We actually found that 14% of the intervention group scheduled earlier appointments, versus only 6% in the control group, and that was significant. We manage complex chronic kidney disease patients who often face barriers to preventive care — everything from competing clinical priorities to social and access challenges. The traditional evaluation times for projects is just too slow for the pace of the care.”

Tanna mentioned that with this test, they wanted to avoid any additional burden on front-line clinicians. "We wanted to make sure we could create a research protocol in which they didn't feel pain and and we were able to do that. We would meet with the team every two to three weeks, and we would talk about how we're protocolizing the experience for patients, and then come up with changes in real time, and then learn from them, and then make more changes.”

West added that the rapid cycle tests are meant to generate rigorous evidence on more of a real-time basis, as Tanna described, so that healthcare practices can actually integrate the findings very quickly, before they even get, official performance or evaluation results from the model.

“We for sure take a look at our summative evaluations to inform what we are interested in testing,” she added, “and I think that it will be a bidirectional flow moving forward as well.”

Tanna added that from the clinician standpoint, this is quite different. “This project shifts the mindset from evaluation after the fact to learning during implementation, quite different from anything we're used to. The RCIP flips that model upside down, embedding learning into the process itself, so our team can adapt in real time. We can refine our workflows; we can re-allocate our personnel; we can scale those interventions that are showing promise. The emphasis on collaboration, transparency and shared learning is really what distinguishes this program and allows course correction during the test, not waiting untill after it's over.”

Last November saw the launch of the West Health Accelerator at Duke-Margolis, born out of a longstanding collaboration between the Duke-Margolis Institute for Health Policy and the nonprofit West Health to advance accountable, value-based care. 

Duke-Margolis catalyzes Duke University’s capabilities, including interdisciplinary academic research and capacity for education and engagement, to inform policy-making and implement evidence-based strategies for better health and healthcare. West Health is a family of nonprofit, nonpartisan organizations dedicated to successful aging and lowering the cost of healthcare in America.  

Since 2018, the two organizations have combined Duke-Margolis’ policy expertise with West Health’s practical experience in care delivery and innovation. The idea is that the Accelerator is powered by interconnected policy and learning hubs that operate a feedback system where evidence from the field informs policy, and policy guides practice. The policy hub translates complex issues into actionable, consensus-driven reforms, while the learning hub generates real-world evidence and facilitates implementation.