CMS Innovation Center Releases New Strategic Vision Under Trump
Post Written by Juliette Price, Chief Solutions Officer, and Jason Helgerson, Founder and CEO
In a white paper entitled CMS Innovation Center Strategy to Make America Healthy Again, a blog post, and an exclusive interview to Modern Healthcare, new CMMI director Abe Sutton detailed the new strategic vision for CMMI under President Trump. HSG unpacks it all for you & shares our first reactions.
New CMMI Director Abe Sutton wasted no time this week getting to the point of CMMI’s new Strategic Plan–it’s all about prevention, turning up the risk on value based care, and bringing new providers into the party, such as independent providers and FQHCs.
What Problem is CMMI Trying to Solve?
This is an often-overlooked question when strategy papers emerge–sometimes called “Question Zero”--and can tell you a lot about how the organization is positioning itself in how it frames the problem it's trying to solve. In Director Sutton’s blog post and in his remarks on May 13, he frames the problem in a few ways:
Medicaid is the #1 expense in most states (fiscal issue)
6 in 10 Americans have at least one chronic disease and 4 in 10 have multiple chronic diseases (quality/outcome issue)
Health care expenditures are growing 2-3% faster than the American economy (fiscal issue)
American’s life expectancy lags 5 years behind other developed countries (quality/outcome issue)
Medical errors are the #3 top cause of death in America (quality/outcome issue)
Medicare trust fund is predicted to be insolvent by 2036 (fiscal issue)
The framing aligns nicely with other CMMI actions this year to return to the department’s organizing mission–reduce cost and improve outcomes/quality.
One Foundational Principle, Three Pillars
The framing then gives way to a set of three pillars that rest on a single foundational principle “protect the federal taxpayer.” This is another reference back to CMS Director Oz’s statement and direction that CMMI focus on alternative payment models that demonstrably reduce spending, and why they shut down several models that did not meet that goal.
Pillar 1: Promote Evidence-Based Prevention
Prevention, prevention, prevention–it’s what we’ve been hearing Secretary Kennedy speak about since he was nominated for the job, and now we’re getting to see what that will mean through CMMI’s lens.
There is reference to three types of preventative work (1) avoiding disease occurrence (including interventions such as nutritional counseling and tobacco cessation), (2) early detection of disease (screenings and diagnostics), and (3) disease management, to slow disease progression and improve management. None of this is particularly revolutionary (ask any primary care provider), but an interesting nugget suggests that “the Innovation Center will contribute to the evidence base of prevention and accelerate progress by testing innovative best practices in medicine and offering new provider and beneficiary incentives.” Interesting tea leaves to read there!
Next, there were varied references about embedding preventative care in all model designs, which is interesting when one thinks about the specialty-focused models, where often a specific diagnosis or type of care needed is the entrance criteria for a model (for example, the ongoing TEAMS model). This seems to imply that models will be changed to have everyone working on prevention in some way.
Measuring the impact of preventative care gets some interesting air time in the new strategic plan–it has historically been a widely-agreed upon fact that good preventative care pays off in the long run, but doesn’t pay the bills in the short term, as we’ve built our health care system fiscal models to favor disease treatment, not prevention. CMMI seems to be implying that they’d like to shift some of the ways we measure the impact of preventative care, including creating intermediate markers of success–and let’s just read between the lines here for a second–and potentially rearrange payment towards those measures? If so, this would spear one of the the white whales of any health care system, which is redesigning the payment system to favor prevention over acute treatment.
Pillar 2: Empower People to Achieve their Health Goals
This section of the strategic plan seemed to be focused on connecting providers and patients to better data, tools, and information to help everyone make better decisions.
The Center seems willing to take the next step towards unleashing the power of data, by both providing more data to patients (there were vague references to new technology for individuals to drive their health goals), making data on cost and quality of providers available to patients, and continuing to work on data flow between the various actors in the health care ecosystem.
A full-throated call for the continued advancement of value based payment models was made, especially models that expose providers to downside risk. In Director Sutton’s interview, he specifically mentions that CMMI will be doing away with the Biden Administration’s goal of having 100% of Medicare beneficiaries in an accountable care arrangement by 2030 in favor of maximizing the number of beneficiaries in downside risk arrangements. To do so, CMMI is actively courting independent providers, rural providers, and Federally Qualified Health Centers/Community Health Centers.
Total cost of care and global risk models are also top of mind for this administration, widening the door for more value based care activity. So are specialty-based models and even pharmacy-based models to reduce costs related to drug spending. We heard clearly from Director Sutton that both revisions to existing models and new models will be out from CMMI later this year.
Pillar 3: Drive Choice and Competition
As mentioned above, CMMI is making clear that it wants a wider variety of providers participating in its alternative payment models–specifically independent providers, community health centers, rural providers, and provider-led ACOs. To entice these providers to join CMMI models, and in recognition that the playing field hasn’t exactly been fairly tilted, the Center seems willing to advance shared savings and prospective payments to support these types of providers in alternative payment models. CMMI even suggests it would be open to collecting downside losses (deficits) over time, to ease the cash flow burdens these types of providers can face.
Medicare Advantage does not escape this new strategic plan untouched, as suggestions of changes to payments for MA plans (inferred risk scores, regional benchmarks, and changes to quality measures all specifically laid out) and site-neutral payments make an appearance in the document.
Lastly, CMMI is admitting that participation in its models is sometimes just too complex administratively. CMMI suggests that it will continue the work of streamlining the measurement sets used across models, and goes further to suggest standard attribution, benchmarking, and quality scoring methodologies across its programs.
Juliette’s Top Musings
Independence Day for Independents: This is your moment if you’re an independent provider, provider-led ACO, or FQHC–this team at CMMI has clearly seen in the data that the bulk of providers reaping the rewards of value based care are health systems and hospital based providers. This is an excellent time to focus on the real powerhouses of value based care–community based providers. These small but mighty players are often outsized drivers of value, they’re just not always invited to the table.
What You Measure Matters: Putting forth the concept that we’re not exactly measuring what matters most is…bold, to say the least. But it’s incredibly important, and a lot of us know that what gets measured gets done, and maybe we’ve not taken a good look at our north star measures in a while. The passing reference to PROMs (patient reported outcome measures) was fascinating to see and a real change of concept. I also applaud the concept of moving from lagging (outcome) measures when it comes to the measurement of preventative care to more intermediate (process or interim) measures.
HRSN…here to stay? While they’ve dropped the “health related social needs” or “social determinants of health” language, CMMI is still talking a lot about community based organizations providing services to patients. Several direct highlights from Director Sutton’s talk were transportation to/from medical appointments to ease access to care, nutrition/diet support, and exercise support programs. If it walks like a SDOH and quacks like a HRSN…perhaps it’s social care services after all.
Devices and Disease Self-Management: If having a payment system that incentivizes prevention is the first white whale of health care systems globally, the other may be truly empowering patients to own their care. The focus in this strategic plan on having patient-facing interventions to manage chronic diseases is intriguing, and I’ve seen amazing results from high-quality programs that blend innovative technology with health care services when they’re needed, such as HealthCareOriginals.
Jason’s Top Takeaways
CMMI gets serious about downside risk: All providers participating in CMMI models will be expected to take on at least some downside risk, even if they join via a convenor or intermediary. CMMI leadership believes downside risk is the only way to ensure providers put maximum effort into lowering the total cost of care. It is a huge opportunity but also a significant challenge for specific providers. I'm very excited to see this commitment.
Evidence-based prevention will replace health equity as the CMS cornerstone: We knew the new administration would pivot away from health equity, but we were unsure where the energy would go. Now we know... they want prevention in all models. What that exactly means is a big TBD. I'm hoping there is an openness to new models of care, including non-clinical interventions such as coaching for individuals with mental health challenges that typically have been hard to cover in overly medical programs such as Medicaid and Medicare. It could also mean that healthy food and medically tailored meals become even more widely available in Medicaid and Medicare.
Level the playing field between community-based providers and their health plan/hospital system competitors: If this happens, it's a significant development. For too long, the bias in American health care has been toward the two behemoths - health insurance companies and hospital systems. Independent doctor groups and other community-based providers such as FQHCs and behavioral health providers have been treated as second-class citizens. CMMI and CMS could go a long way in leveling the playing field. Will it lead to profound changes in the AHEAD program? True site-based payment neutrality? Will it make Medicare Advantage less big insurance company-centric? We will see!
Patient-level incentives may become serious and mainstream: For years, we have nibbled around the edge of patient-level incentives in American health care. The incentives have been low dollar and as a result, haven't moved the needle. CMMI seems open to new approaches, including incentives that drive serious patient empowerment. Will they extend significant shared savings to patients who alter their behavior to lower costs and improve outcomes? If so, this could be one of the most profound changes the new CMMI could launch.
VBP in pharmacy? President Trump's latest Executive Order on prescription drug prices has gotten Abe Sutton's attention. The white paper and his remarks during the live webinar suggest that one response to the order will be new efforts to implement value-based approaches to pharmacy reimbursement. To me, there is a real win-win opportunity here, which is to reward innovation and improved health outcomes while at the same time making new drugs and therapies more affordable for taxpayers. President Trump's call for "most favored nation" status in pharmacy reimbursement is a shot across the bow for manufacturers. Perhaps serious value based contracting is a middle ground where the parties can meet.
Does all of this new direction leave your head spinning? Now’s the best time for your organization to get a clear picture of where you’re headed on the road to value based care. If you’re just getting started or you’re an advanced risk taking organization, HSG is here to help. Drop us a line.
About the Authors: Jason Helgerson is the founder and CEO at HSG, and was previously the Medicaid Director for New York State. Follow him on X and connect with him on LinkedIn. Juliette Price is the Chief Solutions Officer at Helgerson Solutions Group. Connect with her on LinkedIn.
