Experts Discuss Driving Health Equity, Increasing CMS, ACO Alignment

In the opening session of this year’s National Association of Accountable Care Organizations (NAACOS) Spring Conference, NAACOS president and CEO Clif Gaus, ScD, moderated a discussion with Rob Fields, MD, MHA, chief population health officer at Mount Sinai Health System, and Meena Seshamani, MD, PhD, deputy administrator and director, Center for Medicare, CMS.

Throughout the session, both panelists and audience members stressed the importance of the incorporation of health equity into ACOs, while Seshamani offered insights on how the Biden administration plans to improve alignment between Medicare, models, and the organizations.

This year also marks the 10th anniversary of the Medicare Shared Savings Program (MSSP), and despite the fact that “the transition to [value-based care] remains very strong,” more work needs to be done to meet the Center for Medicare & Medicaid Innovation’s goal of having every Medicare beneficiary enrolled in an ACO by 2030, Gaus said.

“We’ve benefitted from a decade of lessons and commitment and awfully hard work driving transition to value-based care,” he noted. But “it does not come easy, and it does not come fast.”

Working with the administration and CMS to make changes in the accountable care model will be crucial to meeting the 2030 goal, Gaus said, adding that accelerating growth with private payers and solidifying primary care as the foundation for whole person care will be paramount in this effort.

Seshamani’s appointment to director of the Center for Medicare also marks a step forward, as she is the first person in the position in a decade to have prior experience in value-based payment; she previously served as vice president at MedStar Health, where she led care transformation.

Advancing health equity, driving innovation, and ensuring affordability and sustainability in care are all central to Medicare’s current mission, according to Seshamani.

“The promise of these holistic care models of transforming care on the ground to really enable and drive all 3 of those pillars that form the basis of the future of Medicare and the vision of Medicare, it is so critical for us [Medicare and ACOs] to partner together to cocreate that,” she said.

Creating synergy between CMS and CMMI to align models and allow for upscaling of successful models is also top of mind for Seshamani, who throughout the session reiterated her interest in hearing from ACOs on opportunities for improvement.

Increasing awareness of the benefits of these models, sharing best practices, and receiving input from patients can help ACOs and CMS achieve the 2030 goal, while concurrently serving to sway opinions of those still skeptical of the transition to value-based care.

Touching on an article published this week in The New England Journal of Medicine by Seshamani and colleagues, Gaus noted the data on the benefits of ACOs are clear, as the article included research that showed quality metrics for providers in MSSP ACOs were superior to those in the Merit-based Incentive Payment System (MIPS).

“Health care is very complex and very personal,” Seshamani said, noting these 2 factors offer a challenge and an opportunity for promoting care transformation. “Being able to share how the work that we do impacts the lives not only of the direct person you're caring for, but their families, their communities,” can help sway naysayers, she noted.

With regard to using alternative payment models and ACOs to drive equitable outcomes in the Medicare population, Seshamani underscored the importance of addressing this mission in health care operations.

“We need to make sure that our health care system is navigable, has comprehensive care, is reliable,” she said. “That, in and of itself, will help advance equity, just having a really strong focus on it in our everyday work.”

Operations of ACOs, as holistic care models, can and do play a big role in driving navigable care and equity, with a focus on moving care upstream to address social determinants of health (SDOH), she added.

Along these lines, supporting providers in rural or underserved areas to engage in models is crucial, and CMS is doing this by working alongside additional agencies like the Health Resources and Services Administration and the Administration for Children and Families, she said. By working with these agencies that have a hand in community outreach, CMS can better incorporate social services into care.

An additional challenge faced by the transition to value-based care is the overall lack of data collected on SDOH and challenges in testing whether equitable outcomes are being achieved, said Fields.

“It seems like government can play a couple roles; one is an enabler and incentivizer, if you will, to do that work. But also in opening up the masses of data, the government has to help understand our population better.”

With regard to incentivizing participation in ACOs, several hurdles exist, including statute-dictated time limitations on bonus payments. To address this roadblock, Seshamani cited CMS’ multipronged approach to working with ACOs to better understand and incorporate appropriate benchmarks and flexibilities.

However, one additional concern in model participation, where incentivization is based upon quality metrics, lies in the fact that providers or practices serving a majority-Medicaid population are judged on the same level as those serving more commercially insured patients, Fields noted.

This may “worsen disparities in the value-based movement because you're disadvantaging those that take care of a higher number of Medicaid patients,” he said. “It is knowable, now, that closing a gap for a Medicaid patient is not the same as closing a gap for someone with commercial insurance.”

Similar issues are raised with regard to rural practices’ participation in ACOs, a problem commonly referred to as the “rural glitch.”

In response to these concerns, Seshamani stressed Medicare is actively working to better engage with ACOs and address problems from a joint perspective.

"Our eyes are open, our ears are open, and we are incorporating all of this information and exploring options here," she said. "We want to grow these models, and we know that there is decision-making that goes on in determining engagement in these models, and it is a multifaceted decision."