CMS Care Model Innovation: The Vision and the Reality

By Mary Tolan
January 11, 2022

In October 2021, the Centers for Medicare and Medicaid Services (CMS) released a whitepaper outlining a revised plan for the next 10 years, after a review of the 50 value-based care payment models set forth over the past decade by that body’s Innovation Center – the CMMI – showed that only six of them resulted in significant savings for Medicare.

In a webinar accompanying the whitepaper’s release, CMMI director Liz Fowler acknowledged that the models were “too burdensome and complex,” and that “overlapping models create substantial confusion.”

The hope, then, is that this new approach will alleviate those issues.

“Moving forward,” she said, “we are committed to create a more cohesive articulation of how all the models fit together.”

Dr. Dora Hughes, the CMMI’s chief medical officer, cautioned on Dec. 15 that new models will likely not emerge until 2023, while at the same time saying that the mission to revise existing models and improve equity is ongoing.

The Five-Part Plan

The CMS plan will apply to the entire national system, with hopes of reducing costs and improving the care and experience provided. The approach will also focus on measuring the effectiveness of these changes.

This five-part plan will address:

  • Accountable Care: The goal is to have all Medicare beneficiaries, as well as the majority of those on Medicaid, involved in an accountable care relationship by 2030.
  • Advancing Health Equity: Underserved populations will be included in all future models, according to the whitepaper, and Fowler said “where possible,” existing models will be revised to “better address health equity, social determinants of health, include more Medicaid beneficiaries and modify financial incentives to achieve outlined goals.”
  • Supporting Innovation and Development: Healthcare lobbyist Cybil Roehrenbeck told the website Fierce Healthcare that the continuing efforts on the part of the CMS and CMMI to extract data from providers will be invaluable, as it will enable these bodies to plot the best course moving forward. And indeed, agility and adaptability will be crucial going forward.
  • Increasing Affordability for Beneficiaries: The whitepaper notes that such measures as incentivizing high-value services using biosimilars and generic drugs can reduce out-of-pocket costs.
  • System Transformation: Delivering services in an efficient manner through Medicare, Medicaid and the Children’s Health Insurance Program while engaging the payers, purchasers and providers to improve the overall quality of care.
Some Concerns

Independent healthcare analyst Joshua Cohen, writing for Forbes in November 2021, questioned whether the efforts of the CMS and CMMI will have the desired effect. He called the CMMI’s “ambiguous,” noting that there is a big difference between cost reductions and a reduction in federal expenditures. And while he acknowledged that reducing wasteful spending is “a win-win situation for all involved,” he questioned whether that is achievable in certain cases.

As he put it:

The CMMI says it is setting “achievable financial benchmarks around which there is a consensus among stakeholders.” However, a reduction in the cost of programs designed to treat difficult to manage sub-populations in Medicare and Medicaid may be a bridge too far.

As a result, he wrote that the CMMI “may need to consider adjusting its criteria of what counts as a successful model.”

The Timeline

It is anticipated that this plan will go into effect immediately, with the CMMI spending the next six months focusing on stakeholder engagement, beneficiary meetings and conversations with health equity experts. Early in 2022, data will be shared with patients, providers and payers. And as Hughes noted, the immediate goal is to revise existing models, and introduce new ones in 2023.

Only in the years that follow will it become clear whether Cohen’s questions can be answered in the affirmative. Only then will we know whether the goals laid out in the whitepaper can be achieved. Certainly the CMS and CMMI have taken a big swing. While that is laudable, there are still many matters that need to be ironed out.