On Sep. 5, officials at the federal Centers for Medicare & Medicaid Services (CMS) announced the creation of an entirely new payment model, known by its acronym “AHEAD”—which stands for “States Advancing All-Payer Health Equity Approaches and Development Model.” The agency’s announcement explained that “States participating in AHEAD will be accountable for quality and population health outcomes, while reducing all-payer avoidable health care spending to spur statewide and regional health care transformation,” the press release states, adding that, “Through this new voluntary Model, CMS will partner with states to redesign statewide and regionwide health care delivery to improve the total population health of a participating state or region by improving the quality and efficacy of care delivery, reducing health disparities, and improving health outcomes. AHEAD also includes specific payment models for participating hospitals and primary care practices as a tool to achieve Model goals. Through AHEAD, CMS aims to strengthen primary care, improve care coordination for people with Medicare and Medicaid, and increase screening and referrals to community resources like housing and transportation to address social drivers of health.”
But will state governments, hospitals, and medical groups really join the new AHEAD Model in large enough numbers to make it successful? One healthcare policy researcher is publicly wondering whether the uptake will be there. In an article published online on Sep. 14 in the Forefront (op-ed) section of Health Affairs entitled “Three Outstanding Questions About CMS’s Ambitious New AHEAD Model,” Troyen A. Brennan, M.D., M.P.H., an adjunct professor of public health at the Harvard T.H. Chan School of Public Health and a former executive vice president of CVS Health, writes that he has some questions. He begins by writing that, “In its effort to move the American health care system away from its corrosive fee for service foundation toward a more efficient focus on population health management and total cost of care, the Centers for Medicare and Medicaid Services in early September announced one of its most ambitious and wide-ranging demonstration projects, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. As with other demonstrations, states will volunteer to participate, applying in the Spring of 2024. Given its sweep, CMS intends to run the program through 2034, with careful annual evaluations. States will be able to access up to $12 million in federal dollars to undertake planning.”
But Brennan thinks that incorporating diverse elements into the new model poses questions, writing that “The AHEAD Model is ambitious indeed. But CMS implies that is the next step in an ongoing evolution from three successful programs already implemented: the Maryland Total Cost of Care Model, the Vermont All Payer ACO Model, and the Pennsylvania Rural Health Model. Each of these have components that have been incorporated into the AHEAD Model, giving CMS some confidence that its expectations are not outlandish and that states will participate. Yet none of the three are an exact fit, and their respective histories do raise some questions.”
For one thing, he notes, in contrast to the Maryland Total Cost of Care Model, “[T]he AHEAD Model does not contemplate the huge Medicare investment necessary to bring federal payments to parity with commercial insurers. It is this feature of the Maryland program that has allowed insurers to avoid “cross-subsidizing” Medicare, and so prompts their continued participation.”
Meanwhile, though the Rural Health Model from Pennsylvania, PARHM, has garnered participation from Highmark, Geisinger, Aetna, and the UPMC plan, but, he notes, “[U] But unfortunately, there appears to be little empirical information on performance yet available, either on cost parameters or population health outcomes. Nor is there any apparent appetite to move the program state-wide.
Then there is a third program that CMS officials considered when developing “AHEAD”: the Vermont program. As he writes, “In contrast, Vermont’s All-Payer ACO Model has been carefully evaluated for years, with the most recent NORC report showing that through 2021, the net Medicare spending for ACO-attributed beneficiaries was $638.80 less than expected per beneficiary per year, or 5.7 percent, with 2021 by far the best year with a 9.7 percent decrease over the expected amount. But Vermont is not an all payer program, nor at this point is it setting global budgets.”
The fundamental challenge for “AHEAD,” Brennan notes, is the question of whether private insurers and hospitals will participate in it. Per that, he says, “The private insurers and the hospitals are only going to get on board if state governments are prepared to push hard to make the AHEAD model work. But how many have that drive and commitment and can reasonably sustain it over a ten year period?” In that regard, he says, Oregon and Massachusetts in theory might be good candidates as state governments. “But,” he notes, “these states would be starting this conversation having already moved forward on their own. What about those states that haven’t already shown such initiative – those with no previous history of work on population health management or cost control? Would they consider participation? Likely not, even though they might have the most to benefit.”
In other words, CMS officials are moving ahead with what he considers a very worthy program plan, but with questions surrounding participation going forward. And in that context, he concludes that “The federal government is trying to do the right thing to promote better, more affordable and equitable care for all citizens. A focus on fixed budgets and population health management must be our future. Some states will take up the challenge and we will learn new things about improving care, addressing equity, and controlling costs -- all of which will lead to a better health care system. But a lot of challenges will have to be overcome, and our current experience with these kinds of reforms does not provide anywhere near all the answers.”
