This post is part of our health equity series. Please read our overview post, Why Health Equity Matters in 2022, to learn more about how you can help advance health equity.
Advancing health equity is chief among the Centers for Medicare and Medicaid Services’s (CMS) new strategic objectives, and from 2022 on, achieving this goal will guide every aspect of CMS’s work. CMS established this new objective in October of 2021 through a complete strategic refresh for its Innovation Center (CMMI) that hinges on five strategic pillars:
1. Driving Accountable Care
2. Advancing Health Equity
3. Supporting Innovation
4. Addressing Affordability
5. Partnering to Achieve System Transformation
These objectives will drive major policy changes and serve as the foundation for the Biden administration’s overarching goal of “creating a health system that achieves equitable outcomes through high-quality, affordable, person-centered care.”
The new strategy was announced in a live webinar, led by CMS Administrator Chiquita Brooks-LaSure and CMMI Director Elizabeth Fowler, and an accompanying white paper: Driving Health System Transformation: A Strategy for the CMS Innovation Center’s Second Decade. Each core objective will be measured and considered in every stage of payment model design, testing, and evaluation, and CMS Administrator Chiquita Brooks-LaSure said, “everything we do at CMS should be aligned with one or more of our strategic pillars.”
Now more than ever, CMS is prioritizing its commitment to promoting health equity, as “ensuring health equity is embedded in every [payment] model” is the number one lesson learned over the past decade. Their new objective defines achieving health equity as “the attainment of the highest level of health for all people” and comes at a pivotal moment. Health disparities are persistent, and COVID-19 recently overturned years of incremental progress towards closing the gaps, exacerbating existing inequities while creating new ones.
Over the past decade, CMMI experienced difficulties thoroughly integrating equity in value-based payment model design and reaching their desired level of impact. Now, the Center plans to incorporate learnings from their portfolio of over 50 payment models, which have reached millions of patients and over 500,000 distinct providers and health plans.
CMMI extensively reviewed past model design, participation, and results, stating that “each of the 50+ models launched in the past decade has yielded important policy and operational learnings” to help accelerate value-based care and produce more equitable outcomes.
Through these reviews and external feedback, CMMI identified the following challenges that have historically limited efforts to advance equity:
CMMI plans to address these challenges with insights gleaned from value-based payment models that directly address health inequalities in their design, such as the Community Health Access and Rural Transformation (CHART) and the Maternal Opioid Misuse (MOM) model. Further, the Center will draw on the CMS Equity Plan For Improving Quality in Medicare and maintain a focus on increasing awareness and understanding of disparities, developing and disseminating solutions to advance equity, and implementing sustainable strategies.
CMMI is focusing their efforts around four key areas to address the challenges detailed above. These actions will broaden the reach of models, provide previously unavailable measures of impact, and help to refine existing models with new learnings. We’ll review each of these four areas below.
According to CMMI, many of their prior models were designed with advancing health equity in mind, but their model portfolio as a whole did not systematically address it or include sufficient demographic measures and impact evaluation. Now, CMMI will thoroughly evaluate and identify opportunities to embed equity across all models—throughout design, testing, and evaluation.
Many past models assessed beneficiaries’ social needs, and CMMI will expand its efforts to utilize screening tools and coordinate with community partners to address these specific needs. This will potentially include testing for certain clinical conditions, evaluating care settings, and introducing models designed to remedy community-level issues associated with social determinants of health (SDoH).
Increasing beneficiary diversity and reaching underserved populations that prior models may not have included is paramount. CMMI notes that beneficiaries enrolled in the Next Generation Accountable Care Organization (ACO) model and in advanced primary care models are more likely to be White, less likely to be dual-eligible, and less likely to live in rural areas compared to other fee-for-service (FFS) beneficiaries in the same markets. Analysis of direct contracting models revealed similar findings.
To extend impact to these previously overlooked, underserved beneficiaries, CMMI will focus on engaging with local communities and public health leaders. Upcoming outreach efforts will target providers that may not have previously participated in value-based care, focusing on providers that disproportionately care for underserved populations. As such, CMMI will review their application and selection process to ensure providers don’t face barriers to engagement and are not disincentivized from participating.
Evaluating the challenges rural providers faced in past models also indicates that safety net providers often require financial and technical assistance to provide equitable care. These providers may lack the necessary infrastructure, and CMMI is considering a variety of incentives to drive and sustain their participation. Potential incentives include, upfront payment, social risk adjustment and payment incentives based on screening, and incentives for collaboration with community-based organizations.
Accurately and systematically assessing model impact on health equity is critical to ensuring long-term program success. In order to standardize evaluation, CMMI is developing new impact assessment measurements and evaluation requirements. Beyond individual models, the Center will also track impact across its entire portfolio and determine how to share model-specific findings with partners and participants. To this end, consistent evaluation will help CMMI iterate on models when applicable and integrate new learnings at scale.
The availability of demographic data that includes factors such as race, ethnicity, disability, and geography is essential to designing impactful models and evaluating their effectiveness. Going forward, CMMI will require new model participants to collect and report demographic data and measure disparity prevalence in their populations. CMMI is also considering new requirements, incentives, and data collection methods for participants in existing models. For example, they are evaluating the use of other federal data sources, such as the Transformed Medicaid Statistical Information System (T-MSIS).
CMMI also aims to share more data with participants and plans to use dashboards to directly deliver information. They are considering augmenting patient and provider data with area-level indices, such as the Area Deprivation Index (ADI).
CMMI shared details about their immediate next steps, providing a closer look at how they plan to execute on their four key efforts. In the near future, CMMI will:
Additionally, CMMI is conducting a series of roundtable discussions to incorporate external perspectives from providers, community-based organizations, and health equity experts. The first of these conversations was held in early December of 2021, and participating stakeholders recommended that CMMI focus on investing in geographically-focused multi-payer models and refining measurement.
While it remains to be seen exactly how CMMI will integrate recommendations and feedback from this discussion series, notable organizations have voiced their approval for both the new strategic objectives and CMMI’s focus on collaboration with partners. The National Association of ACOs (NAACOs) wrote a letter in response to the health equity roundtable, expressing their excitement about the Center’s aggressive stance on advancing equity. They also shared a series of recommendations and proposed several quality measurement changes that they claim will help drive increased program participation.
Ultimately, CMMI’s health equity objective presents an opportunity for HCOs to reduce health disparities across their populations and enroll in models designed to produce and financially incentivize more equitable outcomes. CMMI has stated that they are considering upfront payments, social risk adjustment, and payment incentives for reducing disparities, coordinating with community-based organizations to address social needs, and SDoH data collection. All of these considerations are intended to enable greater participation and may attract organizations that haven’t previously engaged in value-based care.
This post is part of our health equity series. If you’re interested in learning more about health equity and what can be done to achieve it, please check out our comprehensive overview post: Why Health Equity Matters in 2022, and our other posts on health equity:
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