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 all the officials speaking during the one-hour webinar, which began at 1 PM eastern time on Wednesday 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.”
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.
Those six, as Brooks-LaSure outlined them, are as follows:
> “To advance health equity by addressing the health disparities that underlie our health system. As the first African-American woman to lead CMS, I want to make sure that we address these equity issues,” she emphasized. “That will always be the first question we ask, never the last. We are doing everything we can to lift up underserved communities. I had the privilege of joining Governor Polis in announcing the essential health benefits program there,” she said, referring to the fact that, on Oct. 13, she joined Gov. Jared Polis of Colorado in making the following announcement: “Today, the Centers for Medicare & Medicaid Services (CMS), announced it has approved the Colorado health insurance plan that will set the minimum health care coverage requirements starting in 2023. The plan establishes the essential health benefits (EHBs) within Colorado for individual plans (meaning not from an employer) and small group plans (for small employers with less than 100 employees).CMS Administrator Chiquita Brooks-LaSure and Deputy Administrator Dr. Ellen Montz joined Governor Jared Polis, Lieutenant Governor Dianne Primavera, Colorado Insurance Commissioner Michael Conway and Senator Brittany Pettersen to announce the approval at the Governor's Residence at the Boettcher Mansion.” Among other elements, “Colorado’s new 2023 plan will address substance use disorder (SUD) by expanding the number of drugs that insurance companies are required to cover in their prescription drug formularies as alternatives to opioids, as well as adding acupuncture treatments. The new plan adds 15 drugs as alternatives and will cover up to six acupuncture visits per year.” “Health care should be accessible, affordable and delivered equitably to all, regardless of your sexual orientation or gender identity,” Brooks-LaSure said, in the announcement released by the governor’s office. “Today’s expansion of Colorado’s essential health benefits to include gender-affirming surgery and other treatments is an important step towards ensuring equity and access to care for Coloradans.”
> The second pillar that Brooks-LaSure cited: for CMS to “work to integrate the perspectives of CMS stakeholders into our policy and program development.”
> The third pillar: “Building on the ACA and expanding access to quality affordable coverage and healthcare.” That pillar, she said, is explicitly connected to the Biden administration’s “Build Back Better” strategy, and represents “an opportunity to expand affordability and access to Medicare, Medicaid/CHIP, and the marketplaces.” And one element of that, she said, will be “a renewed focus on the Medicare savings programs, to support people’s health coverage.”
> The fourth pillar: “Protecting our programs’ sustainability into the future by serving as a responsible steward of public funds.”
> The fifth pillar: to “drive innovation to tackle our other system challenges and promote value-based, person-centered care.
> And the sixth pillar: “We want to promote innovation: fostering an inclusive workplace, and promoting excellence in all of our operations. We want CMS to be not only a model workplace, but also an aspirational one. I’ve assembled one of the most diverse teams in CMS’s history,” she added, and that diversity itself reflects her desire to foster innovation.
Elizabeth (Liz) Fowler, Ph.D., J.D., the Deputy Administrator of CMS and the Director of CMMI, reinforced many of the points that Administrator Brooks-LaSure had made, emphasizing strongly the concepts of health equity/addressing disparities, innovation, and also, listening actively to concerns expressed by provider leaders.
They were followed in making remarks by several other CMS and/or CMMI officials, including Ellen Lukens and Purva Rawal. Lukens emphasized that all those at CMMI are determined to design models “to target and increase participation in models that support underserved communities and embed health equity.” And, with regard to concerns on the part of provider leaders over benchmarks and other elements in the Medicare Shared Savings Program (MSSP) and other concerns, she emphasized that “We hear you. We understand that model parameters need to be more transparent, easily understood, and less complex.”
All the officials repeatedly referenced the white paper that was released at the time when the webinar was taking place.
The introduction to the white paper began thus:
“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 whitepaper 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.”
The section of the white paper entitled “Lessons from the CMS Innovation Center’s First Decade—Foundation for a Strategy Refresh,” included several key points regarding what federal healthcare policy officials have learned in the past ten years. That section began by noting that “The CMS Innovation Center was established in 2010 as part of the Affordable Care Act with the goal of transitioning the health system to value-based care by developing, testing, and evaluating new payment and service delivery models in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). In establishing the CMS Innovation Center, Congress recognized the need for innovations in payment and care delivery that addressed the two most pressing problems facing the U.S. health system at the time—lower than acceptable quality of care and ever increasing spending that was (and continues to be) a growing burden on households, states, and the federal government.”
Further, the white paper noted, “In the last decade, the CMS Innovation Center has launched over 50 model tests. From 2018-2020, Innovation Center models have reached nearly 28 million patients and over 528,000 health care providers and plans. These models have generated important lessons about how to transition the U.S. health system to value-based care. Models have been launched in advanced primary care, episode-based care, accountable care, state-based transformation efforts, and for specific populations, such as Medicare beneficiaries with end-stage renal disease (ESRD), diabetes, heart disease, and in Medicaid for maternal opioid-use disorders, and populations that experience higher risk for premature births. Each model has yielded important policy and operational insights that will drive the next decade of health system transformation, helping to address not only continued challenges with health costs and quality of care, but also the impacts of inequity and health disparities that have become starkly apparent, particularly during the COVID-19 pandemic.”
After having undertaken a review of the various models that the past administrations had launched, the white paper noted that, “Over the last ten years, only six out of more than 50 models launched generated statistically significant savings to Medicare and to taxpayers and four of these met the requirements to be expanded in duration and scope.” Among the several key points that all the CMS/CMMI officials made on Wednesday was this one: that they will be highly discerning in considering which models to retain, which potential new models to launch, and how to address the concerns of providers involved in all the alternative payment models (APMs).
Among the large number of “Next Steps” in the white paper that are linked to the awareness of CMS and CMMI officials’ stated commitment to improving the APMs, here are a few important ones:
Ø Make available and increase uptake of actionable data, learning collaboratives, and payment and regulatory flexibilities to participants, especially those caring for the underserved, to enable them to transform delivery at the point of care, assume greater levels of financial risk, and use model evaluation to drive dissemination of best practices.
Ø Send strong and consistent signals and expectations about Medicare and Medicaid’s commitment to value-based care so that participants can more predictably make the necessary investments.
Ø Improve sharing of more timely and actionable data with providers to support decision-making at point of care and to identify successful care delivery practices for dissemination.
Ø Encourage and support use of interoperability standards for the exchange of health data
Ø Reduce selection bias by improving model design (e.g., benchmarking, risk adjustment, and care transformation supports) to ensure participation from a diverse group of providers—including those that care for underserved communities—in order to stabilize participation across the life cycle of model tests, and to help meet the requirements for model expansion and potential scaling by other providers and payers.
Ø To avoid risk selection associated with voluntary models, examine whether mandatory models can increase quality and access for beneficiaries, as well as increase provider participation, without negatively impacting those who care for underserved populations.
Ø Consider multi-payer alignment opportunities earlier in model design process.
Ø Complexity of financial benchmarks have undermined model effectiveness.
Ø Many financial benchmarks and risk adjustment methodologies have created opportunities for potential gaming and upcoding among participants — and reduced savings for Medicare.
Ø Set benchmarks to balance achieving the following goals: maximizing provider participation, while sustainably generating savings, limiting spending growth, and motivating continuous improvement.
