Centers for Medicare and Medicaid Innovation Center: Equity and Vision
On October 20, 2021, the Centers for Medicare and Medicaid (“CMS”) Innovation Center (“Innovation Center”) published a white paper detailing its vision for the next ten years: a health system that achieves equitable outcomes through high quality, affordable, person-centered care. The white paper first recounts the last ten years of testing and learning that laid the foundation for the Innovation Center’s future strategy. The future strategy is organized around five strategic objectives that will guide the Innovation’s Center’s models and priorities for the next ten years. The five strategic objectives for advancing this systemwide transformation include (1) Drive Accountable Care, (2) Advance Health Equity, (3) Support Innovation, (4) Address Affordability, and (5) Partner to Achieve System Transformation. These strategic objectives aim to guide the Innovation Center’s models which will seek to reduce program costs and improve quality and outcomes for Medicare and Medicaid beneficiaries. Finally, the white paper emphasizes its approach to measuring the progress of each of these objectives and assessing the impact the objectives have on beneficiaries, providers, and the market as a whole.
CMS Innovation Center’s First Decade: Foundation for Strategy Refresh
The Innovation Center, established in 2010 as part of the Affordable Care Act, began as an initiative to transition the health system to value-based care by developing, testing and evaluating new payment and service delivery models in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). In short, the Innovation Center’s mandate was, and is, to develop healthcare payment models to decrease health care spending and improve health care quality.
In its first decade of operation, the Innovation Center launched over fifty model tests, and from 2018 to 2020 alone, the models have reached nearly 28 million patients and over 528,000 health care providers and plans. To develop the strategy for the next decade of models, the Innovation Center conducted an internal review of its portfolio of models. In addition to the model-generated data, CMS Innovation Center staff examined policy and operational lessons from other model tests, performed an extensive literature review, conducted interviews with experts and stakeholders, and convened focus groups with agency leaders.
As described in a previous Healthcare Law Blog article, “Evaluation of Innovation Center Models,” the Innovation Center’s scorecard over the last ten years shows mixed results. Only six out of more than fifty models launched generated statistically significant savings to taxpayers and Medicare: ACO Investment Model; Home Health Value-Based Purchasing Model; Medicare Care Choices Model; Maryland All-Payer Model; Pioneer ACO Model; and Repetitive, Prior Authorization of Repetitive, Schedule Non-Emergent Ambulance Transport Model. In addition, only four models met the requirements to be expanded in duration and scope: Home Health Value-Based Purchasing Model; Pioneer ACO Model; Repetitive, Prior Authorization of Repetitive, Schedule Non-Emergent Ambulance Transport Model; and Medicare Diabetes Prevention Program Expanded Model.
Based on its review and collection of data, the CMS Innovation Center identified important lessons learned in order to accelerate the movement to value-based care and drive broader system transformation. First, the white paper summarizes the key lessons learned from each model, the issues and challenges faced within each of arena, and the next steps needed to address such issues and challenges. As summarized in the August 12, 2021 Health Affairs article, the new Administrator of CMS Chiquita Brooks-LaSure described the six key takeaways from the Innovation’s first decade:
The Innovation Center should make equity a centerpiece of every model;
Offering too many models is overly complex, particularly when models overlap;
The Innovation Center must re-evaluate how it designs financial incentives in its models to ensure meaningful provider participation;
Providers find it challenging to accept downside risk if they do not have tools to enable and empower changes in care delivery;
Challenges in setting financial benchmarks have undermined our models’ effectiveness; and
Innovation Center models can define success as encouraging lasting transformation and a broader array of quality investments, rather than focusing solely on each individual model’s cost and quality improvements.
Roadmap for Achieving the Vision: Strategic Objectives, Measuring Progress and Next Steps:
The white paper summarizes the overarching goal for the Innovation Center’s next decade: the “health system must recognize and meet people’s medical needs by considering their preferences, values, and circumstances, should strive to keep people healthy and independent, and help providers coordinate care seamlessly and holistically across settings in a manner that puts people at the center of their own care.” To this end, the Innovation Center promises to work more closely with external stakeholders and providers most directly affected by the models in order to facilitate a more intentional focus on addressing health disparities and ensuring equitable access, quality, and outcomes. This includes collaborating across the life cycle of models – from design to evaluation and potentially expansion – and in the implementation of each of the five objectives of the strategic refresh.
For each of Innovation Center’s strategic objectives, CMS set forth the goal of each strategic objective, the method of measuring progress each objective, and a research-backed explanation of each objective, as described in more detail below.
Strategic Objective 1: Drive Accountable Care. The National Academy of Medicine reported that high-quality primary care forms the foundation of a high-functioning health system and is key to improving the experience of patients and care teams, as well as population health, and reducing costs. Therefore, CMS’ first strategic objective, “Drive Accountable Care,” aims to increase the number of people in a care relationship with accountability for quality and total cost of care. The goal is for all Medicare beneficiaries with Parts A and B to be in a care relationship with accountability for quality and total cost of care by 2030 and the vast majority of Medicaid beneficiaries to have the same.
Strategic Objective 2: Advance Health Equity. Healthy People 2030 defined health equality as “the attainment of the highest level of health for all people.” However, evaluations from the Next Generation ACO model showed that aligned Medicare beneficiaries were more likely to be white and less likely to be either dually eligible or to live in rural areas relative to other fee-for-service beneficiaries in the same market areas. Therefore, the second strategic objective, “Advance Health Equity,” aims to embed health equity in every aspect of the Innovation Center’s models and increase focus on underserved populations. To do so, all new models will require participants to collect and report the demographic data of their beneficiaries and, as appropriate, data on social needs and determinants of social health. All new models must also include patients from historically underserved populations and safety net providers, such as community health centers and disproportionate share hospitals. Finally, CMS will identify areas for reducing inequities at the population level, such as avoidable admissions, and set targets for reducing those inequities.
Strategic Objective 3: Support Care Innovations. CMS found that accountable care models, especially those that include total cost of care approaches, will need payment incentives to support the delivery of integrated, equitable person-centered care. Thus, the third strategic objective, “Support Care Innovations,” will leverage a range of supports that enable integrated, person-centered care such as actionable, practice-specific data, technology, dissemination of best practices, peer-to-peer learning collaboratives, and payment flexibilities. To accomplish this goal, CMS will set targets to improve performance of models on patient experience measures, such as health and functional status, or as a subset of Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures that assess health promotion and education, share decision-making and care coordination. All models will consider or include patient-report outcomes as part of the performance measurement strategy.
Strategic Objective 4: Improve Access by Addressing Affordability. While national health spending growth slowed between 2010 and 2019 compared to the previous decade, costs continue to rise at unsustainable rates for both state and federal governments as well as households. Therefore, making health care affordable is an important consideration to driving broad system transformation. Under its fourth objective, “Improve Access by Addressing Affordability,” CMS will pursue strategies to address health care prices, affordability, and reduce unnecessary or duplicative care. This includes setting targets to reduce the percentage of beneficiaries that forgo care due to cost by 2030 and ensuring all models consider and include opportunities to improve affordability of high-value care by beneficiaries.
Strategic Objective 5: Partner to Achieve System Transformation. Achieving broad health system transformation requires collaboration with employers, health plans and states, as well as patients, caregivers, providers and community organizations. Therefore, the final strategic objective, “Partner to Achieve System Transformation” aims to align the Innovation Center’s priorities and policies across CMS and beyond, aggressively engaging payers, purchasers, providers, states and beneficiaries to improve quality, to achieve equitable outcomes, and to reduce health care costs. To this end, where applicable, all new models will make multi-payer alignment available by 2030, and all new models will collect and integrate patient perspectives across the life cycle.
For the strategic objectives set forth above, the Innovation Center will assess the impact in each area according to three categories: (1) Beneficiary Impacts (including patient experience, functional status improvements, population level metrics, quality of care transitions, access to follow-up care, coordination across providers, access to home- and community-based care, access to telehealth services, disparities in outcomes by demographic characteristics, and beneficiary costs); (2) Provider Impacts (including care transformation, impact on administrative burden, level of alignment on models across payers, sustainability of participation in models, and access to actionable data); and (3) Market Impacts (including level of consolidation, new linkages or relationships between providers, spread of model elements to other payers, scalability of model to other regions or payors, and generalizability of impacts to other populations).
CMS Innovation Center Strategy – Moving to Implementation
The Innovation Center outlined a proposed timeline to take place to implement its mission to drive value-based payment and transformation across the health system. The next three to six months are characterized by stakeholder engagement, including listening sessions with beneficiaries, health equity experts, primary care, safety net, specialty providers, states and payers. The Innovation Center also identified an existing model that informs the strategy and transformation. Beginning in early 2022, stakeholder engagement will shift to include outreach to communicate and share the strategies via conferences, podcasts, and events. CMS will launch stakeholder engagement strategies across the life cycle of models, share model test data with external researchers, and leverage existing and new mechanisms to enhance engagement with patients, providers and payers and improve transparency in model design and implementation.
As CMS continues to develop its strategy and application to the Innovation Center’s models, we will continue to share the latest information. In addition, the latest information about the Innovation Center and details about Innovation Center models can be found on the innovation.cms.gov.
 National Academy of Medicine, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021).
 U.S. Department of Health and Human Services. (2021). Healthy People 2030 Questions & Answers.