As we reported earlier, “On Wednesday, Oct. 20, top officials at the Centers for Medicare and Medicaid Services (CMS) and innovation arm, the Center for Medicare and Medicaid Innovation (CMMI) held a webinar for members of the news media, in order to outline their strategy for CMMI going forward. CMS Administrator Chiquita Brooks-LaSure and CMMI Director Elizabeth (Liz) Fowler, Ph.D., J.D., made extensive comments, and were supported by other CMS and CMMI officials, who explained their strategy, in a webinar whose name matched that of the white paper they released at the same moment: ‘Driving Health System Transformation: A Strategy for the CMS Innovation Center’s Second Decade.’”
As we reported, “As all the officials speaking during the one-hour webinar emphasized, CMMI’s strategy going forward will be to help to shift the current U.S. healthcare system toward becoming “a health system that achieves equitable outcomes through high-quality, affordable, person-centered care.” In fact, “Administrator Brooks-LaSure told the remotely connected audience that she is absolutely committed to the goal ‘that CMS serve the public as a trusted partner and steward, dedicated to expanding health equity… and improving health outcomes. To me, everything we do at CMS should be aligned with one or more of our six strategic pillars,’ she emphasized.”
The white paper that the CMS officials discussed at length, entitled “Driving Health System Transformation—A Strategy for the CMS Innovation Center’s Second Decade,” outlines a very major set of policy changes for CMMI, as the flagship innovation agency inside CMS. Its introduction opens with this set of statements: ““The Center for Medicare and Medicaid Innovation (CMS Innovation Center or “Innovation Center”) is launching a bold new strategy with the goal of achieving equitable outcomes through high-quality, affordable, person-centered care. To achieve this vision, the Innovation Center is launching a strategic refresh organized around five objectives. These strategic objectives will guide the Innovation Center’s models and priorities, and progress on achieving goals for each will be to assess the CMS Innovation Center’s work and impact.”
The white paper stated that “The last ten years of testing and learning have laid a strong foundation for the CMS Innovation Center to lead the way towards broad and equitable health system transformation. This white paper describes the Innovation Center’s refreshed vision and strategy and provides examples of approaches and efforts under consideration to achieve the goals of each strategic objective. The Innovation Center’s overarching goal will continue to be expansion of successful models that reduce program costs and improve quality and outcomes for Medicare and Medicaid beneficiaries. In addition, the paper emphasizes how measuring progress toward broader health system transformation is also critical to achieving these goals and vision.”
And Administrator Brooks-LaSure emphasized in her comments on Wednesday, that the following will be the most important priorities for CMMI going forward: improving health equity by addressing systemic health disparities; “work[ing] to integrate the perspectives of CMS stakeholders into our policy and program development”; building on the Affordable Care Act (ACA) to expand access to quality, affordable” healthcare, in the context of the Biden administration’s “Build Back Better” strategy; “protecting our programs’ sustainability into the future by serving as a responsible steward of public funds”; “driving innovation to tackle our other system challenges and promote value-based, person-centered care”; and promoting innovation not only in the healthcare system, but also inside CMS itself as a employer.
So, how big a change is this? It depends on one’s perspective; but clearly, what Chiquita Brooks-LaSure and Liz Fowler said on Wednesday, marked a very big departure from how Seema Verma talked for several years. Instead of Verma’s constant references to “market-driven reform,” Brooks-LaSure and Fowler are talking about how the agency’s policies can drive change. And that in itself is a big change.
One of the profound contradictions in Verma’s stated approach was that she constantly asserted that the capitalist marketplace should help to shape the U.S. healthcare system going forward, even as she increasingly pushed down harder and harder on provider organizations to move into two-sided/downside risk, even as providers told her they simply weren’t ready. Provider leaders, particularly NAACOS, became increasingly involved in a sharp-tongued back-and-forth with Verma over her very aggressive statements around downside risk, at the same time that she lauded market dynamics as a way to stimulate healthcare consumer empowerment. Contradictory? Some saw it thus.
In any case, what’s absolutely clear is that Chiquita Brooks-LaSure, Liz Fowler, and their colleagues, have created a philosophically consistent statement of policy and strategy when it comes to how they want CMMI to evolve forward—as an instrument of change, aimed at ushering in broader and deeper equity and access into the U.S. healthcare system, while at the same time treating providers better, and also at the same time getting more value out of the development of alternative payment models.
There was a sense of chaos, really, about Seema Verma and her leadership of CMS, in particular in relation to how CMMI was run. With its leadership revolving door, contradictions in apparent objectives, and lack of consistent philosophy or strategy, the apparent contradiction between “market-driven” philosophy and extreme heavy-handedness when it came to trying to force providers into two-sided risk, many provider leaders ended up speaking out on that core contradiction.
The sense of relief on the part of provider leaders seemed almost palpable after the change in administrations. Last Thursday, the leaders of NAACOS, the National Association of ACOs, took the opportunity both to praise the performance of Next Generation ACO Model ACOs, based on performance data that CMS had released on that day, as well as to praise Brooks-LaSure and Fowler for the white paper and their statements in the press briefing the day before, Wednesday.
“The impressive Next Gen Model results are the latest illustration of the success of Medicare ACOs, benefiting patients, providers and taxpayers alike. Recent ACO results coupled with an enhanced commitment to accountable care from the Biden administration represent a notable paradigm shift toward achieving healthcare transformation.”
The press release went on to add that “NAACOS was disappointed earlier this year when CMS declined our repeated requests to extend or make permanent the Next Gen program. With the program due to sunset at the end of this year, NAACOS continues to advocate that CMS develop a new full-risk option for ACOs under the Medicare Shared Savings Program (MSSP). This ‘Enhanced Plus’ option would advance ACO participation by creating a full risk and capitation option within MSSP, which to date has only been available in Innovation Center ACO models. This new model would also incorporate new benefit enhancements and incentives and create a better middle ground between MSSP and Direct Contracting,” NAACOS said.
There’s no question that associations like NAACOS are going to continue to press CMS and CMMI officials to give providers the best possible terms under which to participate in all the alternative payment models. In that same press release, NAACOS’s Gaus was quoted as stating that ““Many Next Gen ACOs aren’t moving into Direct Contracting and have expressed a desire to have an ACO option that allows them to more gradually move toward capitation without feeling like they’re taking a step backward in their transition to value-based payment models. CMS could use its waiver authority under the Innovation Center to create a new MSSP option we call ‘Enhanced Plus,’ much like it did with Track 1+, which was very popular and successful.”
The NAACOS press release added further that “Today’s results compare Next Gen ACO spending to their pre-determined spending targets or benchmarks. The CMS Innovation Center has compared spending of Next Gen patients to that of non-Next Gen patients, but the comparison group includes beneficiaries assigned to MSSP and other Innovation Center models. That flawed comparison undervalues the success of the Next Gen model.”
Indeed, the advocacy for better terms seems if anything to be intensifying right now, given the challenging circumstances under which ACOs are operating. Just at week ago, a coalition of 12 national healthcare associations and stakeholder organizations urged Medicare to better account for the COVID-19 pandemic in accountable care organizations’ (ACOs') financial targets. Specifically, the groups, led by the National Association of ACOs, are asking for an option to select pre-pandemic years on which to base benchmarks for their participation in the Medicare Shared Savings Program (MSSP), citing fairness in the way performance is measured in light of the global pandemic.
In the October 14 letter, addressed to Administrator Brooks-LaSure, the 12 coalition members wrote that “The Centers for Medicare & Medicaid Services (CMS) has worked hard since early last year to give our health system and providers the tools needed to fully combat the ongoing pandemic. We greatly appreciate those efforts which have included modifications to value-based care programs, such as those for Medicare’s largest alternative payment model (APM), the Medicare Shared Savings Program (MSSP). However, further policy changes are needed to ensure the shift to value is not derailed by the highly unusual circumstances of the pandemic.”
In fact, they wrote that “The country has seen and continues to experience tremendous variation in how the pandemic is affecting our healthcare system. Some parts of the country were devastated in 2020 yet have now resumed more in-office preventive visits and elective procedures. For other areas, it was the opposite with 2020 providing little change in utilization from previous years, and doctors and hospitals now being hit hard by the pandemic this year. The pandemic has also affected which patients are attributed to ACOs. Since attribution is based largely on primary care services, and utilization patterns have been greatly affected by the pandemic, ACO attribution has been significantly impacted by various aspects of the pandemic, such as patients delaying care. The result for some ACOs has been major differences in ACOs’ attributed populations and performance year expenditures. These are out of an ACO’s control and not necessarily reflected in the benchmarks for which ACOs are held accountable,” the coalition members wrote to the Administrator.
How to keep everything moving forward will pose a very serious challenge to Administrator Brooks LaSure and Director Fowler. On the one hand, their overall strategic and policy thrust is clearly far more coherent than that of Seema Verma; on the other hand, they are managing CMS and CMMI at a time of heightened challenges, with the COVID-19 pandemic costing the federal government more than ever in patient care costs, while also sapping hospitals, medical groups, and health systems of some of their vital financial strengths. Indeed, reports from both the Chicago-based Kaufman Hall consulting firm and the Charlotte-based Premier Inc. health alliance last week documented provider organizations’ considerable financial fragility in multiple areas right now.
So, what’s the right answer to all of this? The answer is that there is no single answer. The pandemic has put pressure on the entire healthcare delivery and payment system as it has put pressure on U.S. society. There is no silver bullet here at all. And the thought process can become byzantine when one attempts to assess who/what should bear more burden right now, in order to get us all through this period in U.S. healthcare history. Should it be purchasers? Payers? Providers? Even consumers? There are simply no easy answers. But one walked away from last week’s CMS/CMMI press briefing with the sense that at least the people in charge have a better idea of what they’re doing—and a more strategic—and inclusive—vision of where they’re going—which is incredibly important.
