Last December, CMS Administrator Chiquita Brooks-LaSure announced the launch of a state-based initiative for the Health Care Payment Learning & Action Network (LAN) to accelerate the movement toward advanced payment models. The State Transformation Collaborative program started in Arkansas, California, Colorado and North Carolina. At this week’s LAN Summit, leaders from those states shared stories about progress on multi-payer alignment.
The LAN, launched in March 2015 by the U.S. Department of Health & Human Services (HHS), brings together public, private, and nonprofit sectors to link healthcare payments to quality and value through the increased adoption of alternative payment models (APMs).
Kate Davidson, the director of the learning and diffusion group at the Center for Medicare and Medicaid Innovation (CMMI), began the panel discussion by saying that multi-payer alignment is a priority for the CMS Innovation Center. “In fact, we've set a goal to include a multi-payer alignment strategy in all new models where applicable by 2030. Our goal is to reduce provider burden and make it easier for providers to engage in value-based care arrangements so we can expand the reach of value-based care to more patients regardless of the payer,” she said. The multi-payer nature of the U.S. healthcare system has meant that any changes in financial incentives by one payer type only have an incremental effect on overall spending and provider finances, she added.
Davidson said CMMI has learned some lessons over the years about multi-payer alignment. “If we align too loosely with other payers, we risk increased provider burden and sending mixed signals to practices. If we require strict alignment, we risk poor participation from our payer partners and disrupting existing innovations taking place through the payment arrangements across the healthcare system,” she said. “We know that if we're going to tip the scales in the proportion of providers’ revenue tied to value — a number that we're thinking is around 60 percent — and change the beneficiary experience by shifting the providers’ economic drivers to adopt a population health focus, we need to directionally align with our payer partners on key design features.”
Davidson said the CMS Innovation Center also has learned that multi-payer alignment opportunities must be considered earlier in the design process. Alignment can start with a focus on core elements of a model, such as outcome measures, care delivery and payment. “Then through data-driven convening, we can deepen our alignment efforts over time with our payer partners to tackle other design features such as attribution, benchmarking and risk adjustment. As a stakeholder in the State Transformation Collaborative, CMS has benefited from the opportunity to learn from and partner differently with a wide range of stakeholders at the local level, where we know that healthcare transformation happens.”
Alice Hm Chen, M.D., chief medical officer at Covered California, the state’s health insurance marketplace, said the area where the Golden State has had the most momentum and tangible success is alignment on quality and equity measurement, with a clear goal of improving population health. “In some ways, this work could be considered a silver lining of COVID, in the context of looking at drops in preventive health and the stark disparities in hospitalizations and deaths for communities of color, and low-income Californians. Many of us paused to reassess how we are approaching quality and decided we needed to do something differently if we wanted a different outcome,” she said.
Covered California is the largest state-based marketplace in the country. It has 1.7 million enrollees, but it also sees a lot of churn, with 40 percent of enrollees leaving from year one to year two. It has an average tenure of about 26 months, “which means that if we want to improve population health, we have to think beyond our own enrollees,” Chen said. “That's what led us to join forces with MediCal and CalPERS [The California Public Employees' Retirement System]. Together we cover about 43 percent of Californians, and importantly, all of us do our work through contracted health plans, and in many cases, the same health plans. So at Covered California, we designed our next-generation quality work, which we're calling the Quality Transformation Initiative in close consultation with both MediCal and CalPERS.”
Most healthcare organizations can't realistically improve on more than a handful of things at a time, Chen pointed out. “We wanted to be very selective about what measures we chose. This also ties back to Kate's point about burden on providers and feeling overwhelmed by the proliferation of measures in the healthcare system. We landed on six: blood pressure control, diabetes control, colorectal cancer screening, childhood immunizations, depression screening and follow-up, and pharmacotherapy for opioid use disorder. And we chose those because those are key drivers of morbidity and mortality. We felt that if we could make collective progress on those, that could actually change the direction of population health. We've tied significant financial consequences to performance, and as we begin to stratify these measures by race, ethnicity, performance for subgroups will also be tied to financial incentives.”
If you think about where most of this work happens, it's in primary care, Chen said. So CalPERS has implemented essentially the same incentive program for its health plans, covering more than 1.5 million Californians. And MediCal has added the six measures as the core of its disparities measure set, and added three or four additional maternal and child measures because they cover 40 percent of kids and 50 percent of births, but the core of their measure set is the same as those of Covered California and CalPERS, she said.
Chen said this work is having ripple effects — the state's primary regulatory agency for health plans, the Department of Managed Health Care, has been charged with developing equity and quality measures that build on this work. “This work has also informed advanced primary care measures developed by purchaser Business Group on Health here in California and is the foundation for a significant multi-pronged effort in multi-payer alignment specific to primary care,” she said.
Colorado’s Primary Care Payment Reform Collaborative
Tara Smith is the primary care and affordability director at the Colorado Division of Insurance (DOI), where she helps lead the DOI’s payment system reforms to reduce health costs for consumers by increasing the utilization of primary care. She said much like California, Colorado sees primary care as central to the effort. Colorado was a state that had robust participation in the previous CMMI models that were primary care-focused — Comprehensive Primary Care Plus and Colorado’s state innovation model, which was focused on the integration of physical and behavioral health, particularly in a primary care setting. “When you look at the sequence of these initiatives, they really did drive both payer and provider engagement in this type of healthcare transformation,” Smith said. “That gave us the time and the space as a state to begin creating forums to really be opening lines of communication, and collaboration and I think even at a more fundamental level, really building the relationships and the trust between the entities that are involved in fundamentally making these models work.”
Multi-stakeholder engagement is foundational to the strategy. In Colorado, the Primary Care Payment Reform Collaborative is an entity that was created in 2019. It is a group of both commercial payers, the state Medicaid agency, and healthcare providers and consumer representatives. “That group has been tasked with developing strategies and making recommendations around how Colorado as a state can be thinking about how we're sustainably investing in advanced primary care delivery,” Smith said.
In terms of alignment, one area Colorado is looking at is quality measures. “We certainly have an eye on what California is doing in that space,” Smith said. “Another area is really looking at patient attribution. As we're thinking about shifting toward prospective payments, particularly in the area of primary care, patient attribution becomes a really important strategy. Risk adjustment is another area that we want to be looking at that we think we will get maximum impact from in terms of payer alignment across strategies with a specific eye on social risk factors.”
Elizabeth Kasper is the special policy adviser for alternative payment models at North Carolina Medicaid. She noted that North Carolina has been in the process of implementing Medicaid managed care for the first time. “In addition to the disruptions and changes that providers all over the country are dealing with in terms of workforce shortages and the strains of the pandemic, in North Carolina we have our providers also navigating a major transformation in Medicaid in how they are paid and what the expectations are,” Kasper said.
“I think because we're doing this alignment work and this STC [State Transformation Collaborative] work in the context of these really major operational and payment changes, it is both a challenge and an opportunity,” Kasper added. “It means we can really bake in an emphasis on value-based payment, which is what we've done as part of our Medicaid transformation, both in the planning leading up to the launch of that about a year and a half ago, and really build it in, not just using these models for the sake of using these models or saving money but really with a broader goal of whole-person care, better quality care. I think we can really bring all these things together toward some unified common goals. We think this sort of alignment is a real opportunity to make it easier for providers to engage in these new ways of providing care and that's particularly on our radar in North Carolina, where we have so much other transformation happening.”
Alicia Berkemeyer, the executive vice president and chief health management officer for Arkansas Blue Cross and Blue Shield, said the work in her state is grounded in primary care, and that Arkansas has had some great success in this past year around convening and collaborating with multiple payers but also having additional stakeholders at the table, including self-funded employers.
“We have had two in-person meetings. At those meetings, the quality work was done in the morning and behavioral health in the afternoon. We had almost 100 participants in person on a Friday. We are really evaluating the data. It is very important for us to ensure that we have timely and accurate data for the providers, but also as important is the member data,” Berkemeyer said. “How do we get that patient in whole-person care to have a more active role in their care? We've got a special group on that as well. We're excited to have some state representatives and governor’s office representation in those meetings, focusing on health equity, interoperability and whole-person care.”