CMS Officials’ Bold Statement of Intent Around Health Equity and Value-Based Care

Jan. 14, 2022
Chiquita Brooks-LaSure, Elizabeth Fowler, and Meena Seshamani have authored a statement of intent as powerful and explicit as any in CMS’s history—and they’ve roped value-based care into their formulation

As we reported on Wednesday, Jan. 12, “The top officials at the federal Centers for Medicare and Medicaid Services (CMS) on Tuesday, Jan. 11, made a major public statement regarding the goal of moving the healthcare system towards health equity, and a major component of that statement focused on leveraging Medicare’s value-based programs, particularly those focused on accountable care organizations (ACOs) to help drive change.”

We noted that, writing in Health Affairs Forefront (formerly the Health Affairs Blog), Meena Seshamani, M.D., Ph.D., Elizabeth Fowler, Ph.D., J.D., and Chiquita Brooks-LaSure wrote of their desire to move forward into health equity, in their article, entitled “Building On The CMS Strategic Vision: Working Together For a Stronger Medicare.” Brooks-LaSure is CMS Administrator; Fowler is Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation, called the CMS Innovation Center); and Seshamani is Deputy Administrator and Director at CMS. In the first paragraphs of their article, the three senior leaders wrote that “[W]e believe that Medicare can contribute to the meaningful, sustainable changes necessary in our health system to put the person at the center of care. Our goals for Medicare mirror Administrator Chiquita Brooks-LaSure’s vision for CMS writ large: advance health equity; expand access to affordable coverage and care; drive high quality, person-centered care; and promote affordability and the sustainability of the Medicare trust funds. In this piece, we describe how we are furthering these goals and available opportunities to better align and partner across the health care system.”

The senior administrators stated very clearly their intentions around health equity, writing that “Medicare will advance health equity by addressing the health disparities that underlie our health system. As women of color who have dedicated our careers to improving health care in the U.S., we know that these disparities have been especially magnified during the COVID-19 pandemic and have put an enormous strain on families and individuals. We must look at everything we do through the lens of health equity, because when the system doesn’t work, it’s those individuals with complex health and social needs who fall through the cracks.”

Very importantly, the three senior CMS leaders didn’t simply speak in generalized, lofty terms about health equity; in the article, they promised to use their management of Medicare’s accountable care organization (ACO) programs and other programs, to support the push for health equity. Indeed, the three officials see the Medicare Shared Savings Program as the perfect vehicle for pushing health equity forward, through bringing care management and care coordination to more and more individuals, including marginalized individuals, in their communities. In that regard, they wrote, “The promise of these care models has become even more evident during the pandemic. Many ACOs, including ACOs participating in the Medicare Shared Savings Program and the Next Generation ACO model, invested in care managers and community health workers who provided critical support to communities struggling to stay healthy. They were able to work quickly to transition to telehealth and continue to provide needed access to care; they provide the team-based services needed to address the full spectrum of issues arising from the pandemic, ranging from community prevention and health-related social needs to end-of-life support for patients, their families, and caregivers. They’ve shown us that better care coordination, providing care not just within the four walls of a hospital, but across the unique experiences of a person, is key to keeping people healthy.”

Furthermore, they wrote, “[A] key part of our strategy will be aligning and coordinating the care models in both Original Medicare and Medicare Advantage. The Center for Medicare is working with the CMS Innovation Center, as part of the Innovation Center’s Strategy Refresh, to align accountable care initiatives and to use the Innovation Center’s authority to test innovative payment and service delivery models  that, if successful, could be scaled into the Medicare Shared Savings Program and made available for more people with Medicare.”

And, “Additionally, the Center for Medicare, Center for Clinical Standards and Quality, and the Innovation Center are working together to help clinicians who are a part of the Quality Payment Program—both primary care and specialists—continue to drive towards value-based, high-quality care. We must also leverage stakeholder engagement, for example through listening sessions and our communications channels, so that people on Medicare and providers, including specialists, better understand these care models and can provide more input into how they are implemented. We must also continue to build our shared learning collaboratives so we can encourage innovation and transformation in care delivery and evaluate and harness lessons learned.”

What I find significant here is that Chiquita Brooks-LaSure, Elizabeth Fowler, and Meena Seshamani see health equity not as something completely separate from everything else in healthcare delivery and payment in the U.S. healthcare system, but instead, as something that can be achieved at least partially through existing frameworks. It’s hard to compare their approach to that of the previous administration, because Seema Verma et al expressed no interest whatsoever in the concept of health equity. But it is intriguing to wonder whether Verma, who made it clear that she was totally focused on what she called “market-driven solutions” in healthcare, would have attempted to align her overall policy goals with specific policies around alternative payment models (APMs). In fact, some in the industry pointed out what always seemed to be a contradiction, in that regard, as Verma was constantly talking about “market-driven solutions,” even as she put intensifying pressure on providers to take on two-sided risk in the MSSP.

That’s not to say that every single initiative coming out of every CMS administration has to be totally aligned with every other initiative. But it seems clear that Brooks-LaSure, Fowler, Seshamani, and their colleagues are determined to move forward with a vision that is both consistent with the overall philosophical thrust of the Biden administration, as translated into federal healthcare policy, as well as consistent with the needs they see out in communities across the U.S. And health equity is a lens that can bring many elements along with it, including the potential prioritization of a very wide range of potential policy choices. And why shouldn’t accountable care organizations and other alternative payment models be enlisted to help support the broader goal of health equity?

Not surprisingly, NAACOS, the National Association of ACOs, immediately released a statement in support of the CMS officials’ broad statement on health equity, noting that “ACOs remain well positioned to advance health equity, another administrative priority, given their accountability to patients’ total cost of care.”

So if health equity is the broad principle, and improvement in outcomes and care management is the transitive verb in this policy sentence, it might just turn out that this laser-like focus on health equity on the part of Brooks-LaSure et al at CMS might end up being the glue that holds the conceptual architecture together, as Brooks-LaSure and her team work to bring together providers to share with CMS the burdens and the opportunities of improving care quality, outcomes, and greater inclusion of patients from marginalized communities, at a time of straitened resources and ongoing policy, operational, and financial challenges. It certainly beats “market-based solutions” as an ideal that the leaders of the nation’s patient care organizations can get behind on an aspirational level. 

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