Skip to main content

What CMMI’s Strategy Refresh means for safety net providers

Innovation that benefits only the privileged is not progress.

While accountable care organizations helped show that a focus on value was missing from healthcare, new ACO priorities reflect that equity has been missing, too — for providers as well as patients. In its recent Strategy Refresh, the Center for Medicare and Medicaid Innovation noted that its “Medicare-focused models have limited reach to Medicaid beneficiaries and safety net providers.”

CMMI’s new ACO model and planned improvements to existing ones are designed to help more providers reap the benefits of value-based care.

If it’s broke, fix it

The objectives of accountable care are clear: higher quality at lower costs, involving less waste and a better experience for all. Those outcomes have not fully arrived. CMMI reports that “only six out of more than 50 models launched have generated statistically significant savings to Medicare and to taxpayers” since 2011. The reasons are many but include the need for a new standard of care that:
  • removes barriers;
  • targets social determinants of health; and
  • prioritizes health equity.
Equity tied to payment reform requires a new kind of data and the resources and infrastructure to support it. Providers who serve the underserved have been at a disadvantage. As CMMI notes, this is “due to investments required for care transformation, complexity of model payment and/or participation parameters, administrative burden, and lack of clarity on long-term strategy for models.”

The pandemic exacerbated these challenges while adding new ones: a much-needed focus on the social determinants of health that dictate 80% of patient outcomes.

New incentives and supports to expand participation

CMMI’s Strategy Refresh is a candid assessment of what 10 years of payment reform has achieved and the aspirations it has left on the table. The report identifies the financial and programmatic supports that safety net providers need to be part of equitable accountable care:

"The Innovation Center is considering a variety of incentives … such as upfront payments, social risk adjustment, benchmark considerations, and payment incentives for reducing disparities or screening for SDoH and coordinating with community-based organizations to address social needs. Technical assistance may include application support, sharing of best practices for caring for underserved populations, and assistance with screening tools and data collection workflows."

The health equity expectation

These new commitments span CMMI and CMS models — from the Medicare Shared Savings Program to ACO REACH. Their intent is to help nontraditional providers participate in incentive models that emphasize accountability and health equity along with CMMI’s other objectives: innovation, affordability and partnership.

CMS’s definition of health equity raises the stakes for all providers:

"[T]he attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes."

CMMI’s goal is to embed health equity across all models with a focus on safety net populations and the providers who see their struggles."

Analytics-forward for equity progress

CMS’ list of “regardless ofs” represents discrete data points that are notoriously difficult to collect, integrate, assess and activate. This puts providers of all types and sizes in a similar boat, regardless of their quality, savvy and access to SDOH data. Addressing complex SDOH needs is difficult, as is obtaining reimbursement for these efforts. Z Codes offer new potential, but the industry is a long way from the standardizations that help make a service and revenue difference.

Equity standards will require a new kind of data strategy and an analytics-forward approach that connects social risk to individualized care plans. CMMI and CMS seek to help providers through learning collaboratives and best practices for accountable care, health equity and financial risk transformation. With this and other data and analytics support, providers who help the underserved may be in a better position to define their destinies.


Popular posts from this blog

Alternative payment models: Strategies for success

In this edition of DataGen Insights, we look at how alternative payment model participants can ensure their processes and workflows are optimally set up for success. To help, DataGen listed the top three strategies all providers participating in APMs can employ and created a handy checklist to enable maximum returns and reduce financial risk. Please explore our website to learn more about our  products and services .  Download DataGen Insights today .  We hope you enjoy!

Why it's critical for Primary Care First participants to control and understand leakage

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly. To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made. Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate: Nuances classifying care delivered by provider team members: It’s difficult to distinguish

CMMI’s New Enhancing Oncology Model – Deadline Approaching

As the final at-risk period for the Oncology Care Model was closing at the end of June, the Center for Medicare and Medicaid Innovation announced its new Enhancing Oncology Model (EOM). EOM aims to improve the coordination of oncology care, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment.  What is EOM? EOM is a voluntary, five-year model set to begin July 1, 2023. Patients undergoing chemotherapy for the treatment of cancer will trigger six-month episodes of care.  Eligible EOM participants include physician group practices with at least one Medicare-enrolled physician or a non-physician practitioner who furnishes evaluation and management services to Medicare beneficiaries receiving chemotherapy for cancer treatment.  EOM participants are required to implement eight participant redesign activities to drive care transformation in their practice. Examples include the provision of patient navigation, 24/7 access to an appropriate c