On Dec. 8, the CMS Innovation Center brought together health equity experts for a roundtable discussion on how federal policymakers can execute on their stated objective to advance health equity. The conversation was moderated by Dora Hughes, M.D., chief medical officer at the CMS Innovation Center.
Alice Chen, M.D., the chief medical officer at Covered California and formerly the deputy secretary for policy and planning and chief of clinical affairs at the California Health and Human Services Agency, said CMMI should focus on alignment, starting with the three M's of Medicare, Medicaid and Marketplace and invest in multi-payer models that are geographically focused, because particularly for vulnerable communities health happens locally, she said, adding that we also need to align on measurement. “There are just too many measures in play, and just too much variation across programs,” Chen said. “The sad truth is that healthcare providers are not equipped to improve on more than a few things at a time. We need a parsimonious set of measures — fewer than 10 — that are core across all the programs and tied to both key drivers of morbidity or mortality, and stratified and targeted for disparities reduction. I would say hypertension, diabetes, colorectal cancer screening are no-brainers,across all these programs.”
Chen added that data is foundational. “We have to move to a place where collection of self-reported demographic and drivers of health data is routine for all programs,” she said. “We need to be clear about why we're collecting it and how we're using it. In some instances, like language, transgender standards, disability and drivers of health, we need it for the point of care. But equally importantly, we need to stratify our data to understand how we're doing and how to prioritize and target investments, and adjust our payment models. For instance, she said, we need to revamp our framework for collecting race/ethnicity data because it's currently confusing, and it leads to incomplete, inaccurate data. We have to move towards a combined race/ethnicity framework.”
Kara Odom Walker, M.D., M.P.H., the former Secretary of Health for the State of Delaware, and a current executive vice president and chief population Health officer at Nemours Children’s Health System, echoed Chen’s comments about multi-payer models. for alternative payment that commit to closing gaps in health equity.
“In Delaware we're trying this with some payers, but the ability to pull all payers together around multi-payer strategies would be tremendous and lift up ACO payment models,” she said. Odom Walker said CMMI should create a financial incentive for innovation and value-based care delivery system reforms and whole person care — “making sure we have partnerships that address the whole needs of an individual physical health; behavioral health; oral health, which is a longstanding challenge; long-term services and supports; and community-based services around social needs would go a long way to addressing those inequities and social needs,” she said. “COVID has shown how interconnected the family unit is to risk and social needs, yet most of our models are based on risk identification at the individual level, not the family or the community level. These overlapping methods to create risk adjustment and social stratification would go a long way to whole person approaches with new financing methods.”
Thomas Sequist, M.D., M.P.H., the chief patient experience and equity officer at Mass General Brigham in Boston, said that when you're thinking about value-based care programs and accountable care organization models, one of the first principles we should all keep in mind is to is like in medicine, first do no harm. “We need to make sure that we understand that the structural racism and other elements of the healthcare system that have disadvantaged patients and the facilities where they receive their care for decades don't get further disadvantaged by innovation programs that are put in place,” he said.
Sequist said it is going to be really important for payers, including CMS, to work with the provider side of the delivery system to understand how we can design payment models that help providers and public health systems address the social risk factors that are preventing achievement of high-quality care. “How do we fund and enable programs that treat food as medicine? How do we fund and enable programs that allow distance care, tele-visits, remote blood pressure cuffs — things that may seem straightforward as an intervention, but when they are not funded and our patients can't afford them on their own, they become prohibitive to achieve high-quality care?”
In addition, there is a lot of work to be done in the digital divide space,” he added. “We have definitely learned across the nation that this is a really critical area for equity.”
Benjamin Money, senior vice president for public health priorities at the National Association of Community Health Centers, described the unique services that community health centers provide and the thin financial margins under which they operate.
“We support value-based reforms focused on investments in comprehensive primary medical, dental, pharmacy, behavioral health, and enabling services, allowing us to operate outside the walls of our clinics to address upstream causes of social drivers of health. Our prospective payment system must be preserved and protected as a foundational payment,” he said. “There is no one APM that will meet all of our needs. We request the opportunity to develop and present to CMMI models that will address our variation in size, locality and scope. Value-based care APMs must build upon the unique comprehensive features of FQHCs, provide upfront investments and operational data and analytics infrastructure, adjust payments for social drivers of health and chronic disease burden,” he said. They must also recognize the FQHC as a medical home, promote team-based care and patient empowerment, invest in successful strategies such as telehealth, remote patient monitoring, and community health workers. “In states that have not expanded Medicaid, we are less able to invest in the infrastructure or value-based payment to necessarily manage the risks and particularly manage downside risk,” Money added.
Veronica Mallett, M.D., the president and CEO of Meharry Medical College Ventures in Nashville, said that one problem is that the current benchmarking in value-based payment programs isn't designed with equity in mind. “It's based on the assumption that historic spending and utilization can always be lowered while maintaining or increasing quality. I would submit that in marginalized and vulnerable populations, that is often not the case. In fact, in order to achieve the desired outcome, more spending more services are often needed, especially initially,” she said. “Those services would include things that are often not covered, like community health workers, remote patient monitoring, social workers, oral and digital health. CMMI should consider incentives for specialists. In states like Tennessee that have not expanded Medicaid, there are many challenges to finding specialists who are willing to take our patients and provide continuous care for the whole patient. This would require that CMMI developed a risk adjustment methodology that considers the historical underinvestment in our communities, as well as the adverse social determinants of health.”
The CMS Innovation Center’s Hughes said that more stakeholder engagement sessions will be held over the next few months.
