CMS Announces "Refresh" of CMMI With Focus on Health Equity, Fewer Models

CMS today announced changes to its Innovation Center’s strategy focused on streamlining model implementation and integration throughout the next decade and addressing social determinants of health by prioritizing inclusion of underserved populations.

As part of the Affordable Care Act, the Innovation Center (CMMI) was created in 2010 and sought to transform Medicare and Medicaid into health systems more focused on value-based care.

In addition to the announcement of this “strategic refresh,” the Center released a white paper outlining lessons learned from the past 10 years and strategies for moving forward. Among the objectives discussed were driving accountable care, advancing health equity, supporting care innovations, improving access by addressing affordability, and partnering to achieve system transformation.

“My vision for the future of the agency, our programs, and the people we serve is straightforward, that CMS serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes,” said CMS administrator Chiquita Brooks-LaSure.

The agency’s renewed focus on mitigating health disparities and promoting equitable access was seen by many as a step in the right direction.

“The shift in focus toward driving more equitable care outcomes is welcome and should help to ensure that all Medicare, Medicaid, and CHIP beneficiaries can enjoy access to high quality care through model redesign,” said Joseph Alvarnas, MD, of City of Hope and editor-in-chief of Evidence-Based Oncology™, in an e-mail exchange with The American Journal of Managed Care® (AJMC®).

Leaders of the American College of Physicians and the National Association of Accountable Care Organizations (NAACOS), similarly lauded the goals of CMS’ Brooks-LaSure and Elizabeth Fowler, PhD, JD, who serves as deputy administrator and director of CMMI.

In particular, NAACOS President and CEO Clif Gaus, ScD, endorsed the goal that every Medicare beneficiary to have a relationship with a provider accountable for their quality and total cost of care by 2030, as well as the white paper’s calls for addressing equity and affordability. ACP President George M. Abraham, MD, MPH, MACP, FIDSA, said the new strategy outlined in the white paper “is closely aligned with ACP’s own objectives for the future of health care,” which the group released last year in a policy statement.

“The recognition by Director Fowler that there are certain differentiated areas in healthcare, including oncology, sets us up for success in moving forward with more equitable care delivery models,” Alvarnas added.

Added Kashyap Patel, MD, CEO of the Carolina Blood and Cancer Care Associates and associate editor of Evidence-Based Oncology™, “So far, models have focused on cost, quality and patient experience. [Adding] equity as one of the factors is a welcome change.”

CMMI stressed it aims to improve both data availability and communication with stakeholders for practices participating in models, and hopes to make complex, overlapping models more transparent and streamlined.

The siloed, disjointed nature of models in the past has served as point of frustration for practices. “Whether it's data or the processes [that] are sort of siloed within organizations, there's not a lot of sharing across organizations. And I think hopefully this [strategic refresh] will help to spur some more of that going forward,” said Rick Chapman, PhD, the chief scientific officer at the Innovation and Value Initiative (IVI), which had previously released its own principles for value assessment. Chapman also praised the emphasis on partnerships to propel health care transformation.

However, for practices enrolled in the Oncology Care Model (OCM) slated to end in January 2022, little detail was given regarding the seemingly inevitable gap between the program’s end and implementation of any successor program. In November 2019, the Trump administration announced plans for Oncology Care First, a successor to the OCM that was never implemented due to the pandemic.

This may have dissatisfied some oncology practices who were hoping for more clarity on what to expect next once the program ended.

CMMI’s thinking in terms of refreshing their strategic priorities is very broad, explained Stephen M. Schleicher, MD, MBA, a medical oncologist at Tennessee Oncology and medical director of value-based care at OneOncology.

“Cancer was mentioned once or twice, but…a lot of the focus was on, importantly, underserved populations, equitable care, access to care, which are all extremely important. But I felt the tilt was towards primary care accountable care organizations,” Schleicher said in an interview with AJMC®. “I'm afraid that priority on a next generation cancer model may be even more delayed than I think some of us had hoped.”

Although the strategy refresh does not mean the CMMI plans to end models early, “the 5 strategic objectives of the strategy refresh will guide revisions to existing models, as well as consideration of future models,” said Fowler. “So, where possible, current models may be modified, for example, to better address health equity, social determinants of health, for example, include more Medicaid beneficiaries and modify financial incentives to achieve outlying goals. Existing models might also benefit from greater innovation and payment waivers,” she added.

As part of the refresh, CMMI plans to hold regular listening sessions going forward to hear from stakeholders.

The rise of alternative payment models (APMs) comes from the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which put more details on the procedures for moving away from fee-for-service (FFS) payment that was first envisioned under the ACA.

But as discussed in the CMS white paper, often the APMs were voluntary, complex, and without adequate support for practices or health systems to take the plunge and move into a full-risk environment. Although the white paper does not offer many details, it does suggest a future reimbursement system that will call for more risk but offer more support in exchange for more data-sharing to ensure that the health care system is delivering care in an equitable way.

Chapman, of IVI, the today’s action by CMS should accelerate the movement toward integrated care called for under MACRA. “For those who were reluctant to use [APMs] before, I think it may help to alleviate some of their concerns, as it will be a more streamlined system,” he said.

In the early years after MACRA, Chapman said, “some of it was just that the data were there, but we weren’t pulling it through and putting it into use. So, I think this could accelerate that process.”