At the recent Value-Based Health Care Congress meeting, Purva Rawal, Ph.D., the chief strategy officer at the CMS Innovation Center, spoke about engaging more safety net providers and developing more value-based care models that involve Medicaid as part of the larger focus on health equity.
Before joining the Innovation Center, Rawal was a principal at CapView Strategies where she developed evidence-based public policy and business strategies for providers, health systems, life sciences companies, and coalitions, and conducted policy research on health system transformation and sustainability issues. She is also an adjunct assistant professor at Georgetown University.
Rawal said she thinks of value-based payment as a means to an end, and the end is better outcomes and quality for patients in a more sustainable system. “That means broadening the reach of who gets value-based care. That means all populations and advancing health equity has become one of the most important areas of focus for the Innovation Center, and for CMS and HHS more broadly,” she said. “We're committed to embedding equity into all aspects of our models, and increasing our focus on underserved populations. A lot of this work is being led by Dr. Dora Hughes, the chief medical officer at the Innovation Center.”
She said CMS and the Innovation Center need to understand the barriers to participation for different providers, especially those providers that care for underserved populations. “We need to address those barriers to participation, especially for those providers that are caring for a high proportion of underserved and rural beneficiaries.” She said they also are committed to engaging a broader range of safety net providers — federally qualified health centers, rural health clinics, and others. “That's actually an area I think is ripe for collaboration for understanding some of the payment challenges that we have to overcome, but also for those providers who may not be safety net providers.
Rawal noted that historically the Innovation Center has launched more Medicare-focused models, and that a focus on Medicaid is a key part of the strategy refresh. “Medicaid plays a crucial role in engaging disadvantaged or underserved populations. And in fact, one of our lessons learned is that the full diversity of our beneficiary population in Medicare and Medicaid is not reflected in our models today,” she added, “so that's a huge area of focus.”
“Given these lessons learned, we want to be able to launch more Medicaid-focused models, and maybe modify existing models to include Medicaid beneficiaries,” Rawal said. “A critical part of this is our multi-payer alignment strategy. When we're thinking about building a model on the front end, can we build it so that more payers can come in?”
Collecting and using data
Rawal was asked to speak about improvements in data collection and sharing. “If we don't have the data, it's very hard to make sure that we are providing the right financial incentives to the right providers and beneficiary types,” she responded, “but collecting data for the sake of the data doesn't mean anything. We really have to have to drive model design, and, where we're making investments to address lower life expectancy, access issues, and, striking and glaring disparities that have really been illuminated with COVID.”
She said CMS has plans to support model participants to collect data on demographic characteristics, race, ethnicity, geography, and other demographics, to support monitoring in CMMI models and evaluation in a HIPAA-compliant way.
“We're hoping that model participants will report these data to the Innovation Center in order to help providers address disparities,” Rawal added. “We also plan to go a step further beyond collecting the data and reporting back. We also plan to collaborate with model participants on targeted learning opportunities, such as how do you collaborate with community partners to address social needs that have been identified. We're also in the process of implementing a more deliberate and consistent approach within the Innovation Center, as well as across CMS, because it really has to be an agency-wide coordinated effort in quality measurement and evaluation. We're assessing the impact of models on underserved populations, so we can really close those disparities in care and outcomes. Those are the kinds of data that we can also then use to think about additional supports for safety net providers of those caring for underserved populations. Are there different financial incentives that we might need to make to ensure that those providers are able to enter into value-based payment arrangements and be successful in them as well?”
Integrating behavioral care and social services
COVID has been a tragedy, Rawal noted, but it has pushed a lot of issues to the forefront that we've known are there. “I think there's a greater acknowledgement when we think about behavioral health and social determinants of health how all of these things really are connected and come together. We are thinking about whole-person care in terms of our model development,” she added. “We know it's ambitious, but we want to be working with partners to be able to build those incentives that create the delivery systems to provide integrated, whole-person care. We think person-centered care integrates an individual's clinical needs and social needs, across providers and settings. I think a big area where that can be explored is greater integration between primary care and behavioral health, and also care for beneficiaries with complex needs and serious illness.”
She noted that CMS has tested beneficiary engagement incentives such as offering transportation and other provider payment arrangements that otherwise wouldn't be allowed in fee for service. “We're going to continue to test those payment regulatory waivers and flexibilities, but we also want to emphasize those in particular that allow patients to be able to get care in the home or in the community, especially as we move toward total-cost-of-care models. We want to be able to offer that flexibility.”
The Innovation Center is also thinking about ways it can further support providers through actionable practice-specific data — more timely data that is helpful at the point of care, or for care management, she said. “Obviously, technology plays a role here, as does the dissemination of best practices, and peer-to-peer learning collaboratives. The Innovation Center has a learning diffusion group that leads a lot of that work, and we've had success there and want to be able to broaden that.”
Primary care models
The Innovation Center is thinking very hard about primary care, Rawal said. “I think it is critical to us achieving the goals that we've laid out. We've learned that primary care practices can transform the way they provide care if they have the right incentives and resources, which can often include training, technical assistance, support and data on their patients and who they're serving,” she said. In the Comprehensive Primary Care Plus program, for example, practices have started making their facilities more accessible after hours for patients who need it. “We are seeing greater accessibility for patients as a result of participation in the program. From our perspective, practices have started to deliver care that's more patient-centered and patient-focused by increasing their use of care managers and integrating behavioral health,” she said. “We're seeing some of the building blocks you can put into place that allow that kind of care transformation and integration to occur. And we started to see some of this also translate into favorable outcomes. CPC Plus in year three started to actually show slight decreases in ED and hospital utilization as well. We've also learned, like with any model, incredibly useful but sometimes hard lessons as well."
Moving practices away from fee for service and into population-based payments is not easy, she noted. If practices are smaller and don’t have as much experience with value-based payment, they require more training and investment. "We have to think hard about how to get some of the smaller, more independent practices involved, and that that requires a different investment and a different set of tools.”
She added that CMS has learned the hard lesson that primary care investment takes time to yield savings. “I think four to five years has not proven long enough to recoup the upfront investment that you really need to make to drive the care transformation. We also know that some of our primary care models have tended to attract practices that are not necessarily providing care for underserved populations,” Rawal explained. “That means that our beneficiary profile may not be representative of the population as a whole. That is something we have to think hard about — how do we get a broader swath of practices and safety net providers in? We have also tried to work with payer partners on these models and tried to have a multi-payer component to these models.”
There is a recognition that one size does not fit all for primary care practices. “When we're moving to value-based care, some practices are more ready than others to take on risk,” she said. “Some practices need more investment help. But as we think about working with a broader swath of providers, where we're going to have to be nimble is in thinking about what different provider types are going to need to make this transition and be successful.”