CMMI’s Pauline Lapin Describes Unified Vision for ACOs

Jan. 24, 2022
CMMI looking to attract providers not currently participating in ACO initiatives, such as those who are serving underserved populations or in rural areas

The CMS Innovation Center has stated a goal of having all Medicare patients aligned to an accountable entity by 2030. At a Jan. 24 Value-Based Care Summit meeting, Pauline Lapin, M.H.S., the director of the Seamless Care Models Group (SCMG) in the Center for Medicare and Medicaid Innovation (CMMI) described the unified vision for accountable care organizations that CMS is working from in its strategic refresh.

“What we're looking for is a vision that can attract providers that are not currently participating in ACO initiatives, such as those who are serving underserved populations, or who are small or are in rural areas, as well as organizations that maybe have other types of barriers to entry,” said Lapin, who has overseen and provided guidance in the development and implementation of innovative payment and delivery models related to advanced primary care and accountable care organizations, including the Comprehensive Primary Care (CPC) and CPC Plus initiatives, the Pioneer ACO and Next Generation ACO Models, and the Comprehensive ESRD Care initiative.

Lapin said they are also looking at how to create sustainable financial incentives that can attract both efficient and less-efficient organizations — those experienced and less experienced in population-based models. They want to drive greater collaboration between ACOs and specialty care to achieve greater value and efficiency.

“As we work together on this unified vision, we know that having different rules and methods is not only confusing, but it also has led to selection issues and ACOs maybe choosing to participate where benchmarks are most favorable for them, and in regions of the country where they can be successful,” Lapin said. “Our unified vision will aim to improve patient care and experience. We've been on this journey around value-based care for over 17 years, dating back to the Medicare physician group practice demonstration, to examine how we can promote better care planning and relationships between patients and providers, and create a system of care that meets all their needs, including access to community and social services.”

Because health equity is central to the vision, CMS will seek to attract all types of providers, including those that serve underserved beneficiaries. “We want to make sure that health equity is embedded in everything we do. We're looking at all the features of our models, all the tools at our disposal — how we design financial methodologies, including benchmarks and risk adjustment, how we recruit safety net providers, our quality measurement and data collection approaches, and even our shared ACO learning community, which has been really valuable in disseminating best practices,” Lapin said. “How can we learn from each other about best practices to address health disparities in care and outcomes? We've been on this journey together with the Shared Savings Program for many years and have a lot of lessons that we are learning that will inform the future direction, and it's a really exciting time to be working together.”

Lapin was asked what are some of the lessons learned from the different ACO models.

She noted that evaluators are still conducting their research looking at the Next Generation ACO model, but those ACOs have invested in four major areas: They improved their data analytics capacity. They engaged beneficiaries through providing better care management, annual wellness visits, and other types of strategies. They engaged their physicians using financial and non-financial incentives. And they collaborated with skilled nursing facilities for better delivery of post-acute care.

CMS also saw that there was a decline in gross Medicare spending that increased over time. “However, after netting out payment of shared savings to the Next Generation ACOs, our cumulative spending over the four years of the model so far indicates net losses to the trust fund,” Lapin said. “That's why we need to do a little bit more analysis and learning around how we set benchmarks. And this is true across all of our ACO and risk initiatives. The benchmarking methodology is really important to understand.”

Asked about the Direct Contracting model currently under way, Lapin said they are hearing about innovative strategies and partnerships that are being created to address overall health needs of beneficiaries. “For example, we have a safety net provider that told us the story of an African American male with multiple chronic conditions, who over the course of having multiple chronic conditions, also had multiple emergency room visits. And this participant developed an intensive program focused on their highest-risk population, which includes in-home visits with a dedicated nurse practitioner and social worker. This beneficiary reported that he's using the ER less because he's learning now how to use urgent care and primary care. He also received a scale to help monitor his weight. Given that he has congestive heart failure, he needs to be monitoring his weight on a daily basis. And he really finding value in being served by this safety net provider that's part of the model.”

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