Posted on November 5, 2021 by Kyle Walton
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Posted on November 5, 2021 by Kyle Walton
As a major functioning body of the U.S. Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) is designed to administer basic health services, specifically Medicare services and Medicaid services, alongside state governments.
Headquartered in Baltimore, Maryland, the CMS currently serves more than 46 million diverse and widespread Americans. Typically, the most common recipients of CMS programs include pregnant women, infants, elderly Americans, low-income adults and children, and disabled individuals.
Over a decade ago, the Affordable Care Act was passed in an effort to create a more value-based system that reduces government spending while aiming to preserve and enhance the quality of American healthcare.
At the time of its enactment, the Center for Medicare and Medicaid Innovation, known colloquially as the Innovation Center, was also created. The original purpose of this organization was, and continues to be, protecting Medicare’s financial stability, state Medicaid budgets, and household spending.
Now, CMS Administrator Chiquita Brooks-LaSure, and several colleagues are reflecting on the successful past and hopeful future of the Centers for Medicare and Medicaid Services and the Innovation Center.
After a decade of launching more than 50 alternative payment models that are intended to reward healthcare providers for delivering high-quality care at a more efficient cost, the Innovation Center has learned a significant amount about developing a path for sustainable healthcare.
Of these 50+ models, only six have successfully generated statistically demonstrable savings for taxpayers and Medicare, and only four have met the requirements for expansion in duration and scope. In review, what the CMS has learned over the past 10 years primarily generates three key takeaways:
To date, most models have been mostly Medicare-oriented, while voluntary models have seen limited participation by healthcare providers, primarily because so few organizations have the resources and capital to fully participate out of their own accord.
Recent findings have made it clear that ensuring that everyone has access to providers at the cutting edge of medical treatment should be a primary focus. Prioritizing equity across the Innovation Center’s portfolio will help to ensure that value-based outcomes are clearly and fairly measured for everyone involved.
As stated, the Innovation Center has launched over 50 models since its inception. Currently, over 28 models are running simultaneously, often overlapping in many key areas. As it turns out, testing too many models at once can often create opposing and even conflicting incentives, burdening model participants with overly-complicated hierarchies and interactions.
As a result, decisions about joining or continuing to participate in a given model can be challenging, and only serves to stymie scalable systematic transformation in the world of affordable healthcare.
When the CMS Innovation Center set out to transform American healthcare and health insurance programs, a large model base was desired, as leaders and experts thought greater quantity would result in a higher likelihood of achieving proof of concept.
While this did occur, unforeseen challenges associated with the government cost and private provider expenses quickly overshadowed the Innovation Center’s ability to accurately determine model effectiveness. These issues must be addressed and corrected in order to truly achieve value-based, transformational healthcare in the United States of America.
The Innovation Center’s ultimate vision is achieving a healthcare system that provides equitable outcomes through high-quality, affordable, and person-centered care. In order to deliver on this promise, the CMS must continue to develop a system that keeps individual citizens happy and healthy while seamlessly coordinating care across all settings. To accomplish this, the CMS issues the following statements:
Going forward, the Innovation Center will be embedding even more equity in its future models by seeking to include more providers who serve low and modest-income families and citizens, racially diverse populations, and/or rural populations.
In addition, while voluntary models can and do demonstrate proof of concept, they unfortunately limit potential savings and the CMS’s full ability to test intervention because participants often opt in when they believe they will benefit financially, and opt out (or outright refuse to join) when they believe they are at risk for profit loss.
To combat this issue the CMS Innovation center must reevaluate its incentive design entirely, shifting the focus to achieving even greater provider participation.
As the CMS Innovation Center continues to identify practices that work effectively in models, there must be an even greater commitment to ensuring their scalability. Whether this goal is achieved through certification, expansion, or by incorporating the demonstrated benefits of these models into future efforts, lasting value-based healthcare transformation must be placed at the forefront of the industry.
In order to truly achieve an American healthcare system that results in equitable and beneficial outcomes for everyone involved, a greater emphasis must be placed on high-quality, more affordable, and more person-centered care. According to the Innovation Center five strategic steps will be taken in an effort to accomplish this goal:
Accountable care means that providers are rewarded when they deliver high-quality, coordinated, and team-based care that proactively promotes nationwide health, and are held accountable when they do not.
CMS must develop a system that attains the highest level of health for all Americans, and eliminate healthcare disparities in the process.
To achieve this goal, equity must be centered in model designs that engage providers in value-based care for historically disadvantaged populations, including racial, ethnic, and rural communities, those with disabilities, and those who may not have had previous healthcare relationships with these providers.
Intentionally building in partnerships with state Medicaid programs, for example, will be an essential move.
CMS must continue to support innovation when it comes to care delivery that is intended to drive optimal outcomes. In order to accomplish this, some providers may require additional tools that will help them better deliver care to patients both in their homes and in their communities.
Work in this area will also include the support of model participants through investment, real-time data provisions, and the creation of payment rule waivers that increase flexibility.
The Innovation Center’s purpose is to test innovative payment and service delivery models to reduce program expenditures for Medicare services and Medicaid services, but the true value lies in the CMS’s ability to focus on lowering out-of-pocket healthcare costs for patients.
Going forward, the Innovation Center will seek to meet its statutory mandate while simultaneously addressing affordability issues directly, both for Medicare and Medicaid beneficiaries and the healthcare providers who administer service and treatment to them.
Medicare is without a doubt an important driver for systemic healthcare change, but Medicare cannot achieve the level of transformation that American citizens deserve alone. For this reason, a greater emphasis must be placed on developing strategic partnerships with not only state Medicaid agencies, but additional entities that have relationships with healthcare payers, purchasers, providers, patient advocates, and community-based organizations.
After all, the success of the CMS and its Innovation Center models hinges directly on the multi-payer alignment of clinical tools, outcome measures, payment, and policy approaches.
Chiquita Brooks-LaSure and her fellow CMS leaders are committed to the development of both short and long-term objectives in the world of affordable healthcare, especially as it pertains to Medicare services and Medicaid services.
In the coming months, you can expect even more details about the Innovation Center’s upcoming models. For now, more information about CMS, the Innovation Center, and the aforementioned models can be found at https://innovation.cms.gov/.