Remarks from Recent CMMI Listening Session

  • Published on:
  • November 30, 2021

Dear Colleagues,

As we think about caring for the most vulnerable in our society, we need to ensure health equity by reducing disparities in care among different populations. At this moment in time, we have two historical events clashing together as one: we have the catastrophic public health crisis and resultant economic fallout from the COVID-19 pandemic, and we have the plight of racial injustice in our society.

The industry movement to value-based care emerged more than two decades ago to improve quality while containing costs. However, its impact on racial health disparities has been limited. That is now being rectified by policy leaders looking to reengineer payment models to include health equity as a key financial measure for success. The future of value-based care necessitates evolution to continue and accelerate forward progress towards health equity.

 As Mark McClellan (one of the ACLC co-founders) and his co-authors wrote in a recent Health Affairs blog, more purposeful accountability and model design is necessary to improve health equity. This will require basing prospective payments to providers on interventions that support the delivery of services (e.g. nutritional support, transportation support) that can address social factors leading to disparities in health outcomes.

On October 20, 2021, the CMS Innovation Center (CMMI) released a Strategy Refresh white paper, cementing their vision for advancing health equity, as well as driving accountable care, supporting innovation, addressing affordability, and partnering to achieve system transformation.

As part of their commitment to partnership, CMMI is conducting listening sessions and inviting stakeholders to respond to questions such as:

  1. What is the greatest obstacle to participating in a CMS Innovation Center or other value-based, accountable care model? How do you recommend the CMS Innovation Center alleviate this obstacle? For example, this could be related to resources, requirements, model designs or other issues/obstacles that have made it too burdensome to participate.
  2. What else could the CMS Innovation Center do to support clinicians and help them be successful in models? For example, this could include more timely and actionable data, learning collaboratives, and payment and regulatory flexibilities.
  3. How can the Innovation Center better incorporate patient needs and goals into models? How should the impacts of value-based care on patients be measured? For example, this might relate to how the CMS Innovation Center should gather input from or improve responsiveness to community needs, or other thoughts on how the Innovation Center can incorporate and measure impact on patient needs and goals.

The first listening session was held on Thursday, November 18 and included speakers from provider groups, associations, and others who – like the Accountable Care Learning Collaborative – support the transition to value in health care. A transcript and slides from this discussion have been posted to the CMMI website for Strategic Direction. I also want to share with you a high-level overview of the call.

The call began with remarks from CMMI leadership, including Liz Fowler, who described their commitment to improving transparency and communication, as well as understanding and addressing barriers to model participation for providers.

Stakeholders then provided feedback on the questions posed by CMMI, and the following themes emerged. I especially endorse the first three themes, and have heard similar concerns from many of you:

  • Create a “level playing field” for provider participation
    • Smaller practices may be squeezed out when big capital dominates
    • Prospective or other upfront payments can help with needed infrastructure investments (e.g., for scale of up staffing, technology, new care models, etc.) that often are barriers to model participation, especially for those in practices that are smaller, rural, and/or serve a substantial number of patients with Medicaid
  • Address inequities in benchmarking and risk adjustment methodologies
    • Benchmarks and incentives may punish those who are already high performing and promote a “race to the bottom”
    • Benchmarks and risk adjustments do not enable optimized care for disadvantaged populations, who may have a history of under-utilization of healthcare services
  • Enable access to more meaningful, comprehensive, and timely data
    • Some model participants have had to purchase data from Qualified Entities and others in order to appropriately analyze and monitor their own performance and risk
  • Reduce administrative and regulatory barriers
    • FQHC and Critical Access Hospital participation in models is inhibited by regulatory and reimbursement complexities
    • Reporting across models is not streamlined, in terms of data platforms or content
    • Employ waivers to provide more flexibility (e.g., for home care, transportation, meals)
    • A longer glidepath is often needed to both evaluate and then scale up for successful model participation
  • Reduce overlap and improve collaboration between models
    • Beneficiaries in specialty care models, such as the renal- and oncology-focused, should be aligned with the providers in those models, rather than attributed to other providers (such as Direct Care Entities)
    • Promote communication between accountable providers through existing systems like Health Information Exchanges
    • Find ways to leverage the learnings from models into existing programs and regulations – even from those models who have not met the statutory requirements for expansion

Stakeholders who shared their remarks with CMMI include:

  • Lance Donkerbrook - CEO, Commonwealth ACO  
  • Misty Drake, VP of Client Services, Medical Home Network
  • Kate Freeman, Manager of Payment and Care Transformation, AAFP
  • Nitin Jain, President VBC, US Renal Care  
  • Joanna Hiatt Kim, VP of Payment Policy, AHA
  • Mark Lamm, Director of Population Health, LifePoint Health  
  • Lisa Leveque, VP of Strategic Alignment & Care Transformation, Bandera Healthcare  
  • Larry McNeely, Director of Policy, Primary Care Collaborative 
  • Jeff Miklos, Executive Director of Health Care Transformation Task Force  
  • Aisha Pittman, VP of Policy, Premier  
  • Laura Thornhill, Director of Regulatory Affairs, Alzheimer’s Assn 
  • Kelli Todd, ACO Director of Govt Programs, UnityPoint Accountable Care
  • Jessica Walradt, Director of Performance Based Reimbursement, Northwestern Medicine  
  • Lalan Wilfong, VP of Payer Relations & Practice Transformation, McKesson  
  • Terry Williams, Executive VP and Chief Population, Corporate & Government Affairs Officer, Atrium Health
  • Allison Brennan – Senior VP of Government Affairs, NAACOs

In October of 2020, I interviewed Cheryl Lulias, the CEO of ACLC member organization Medical Home Network (MHN) and I appreciate the thoughtful comments posed by Misty Drake of MHN during the listening session. We need more leaders like those at MHN who are improving care for thousands of patients every day through innovation and transformation, especially via their commitment to advancing health equity and reducing disparities in health outcomes. I echo the recommendation to “leveling the playing field” that could result in improved health outcomes for patients and greater involvement in models by high quality organizations like MHN ACO

I was also particularly struck by Allison Brennan’s comments on the level of “stamina” that is often necessary for navigating participation in Alternative Payment Models. Burnout is endemic across health care, and model administrative complexity should not be an additional pain point for our health systems to endure.

I appreciate the opportunity to participate in this listening session and the responses provided by CMMI leadership during the call. The next call, a roundtable discussion focused on health equity, is scheduled for December 8. I look forward to this next opportunity for dialogue and moving to action in collaboration with CMMI, so we can work together to remove barriers and engage more of the US health system in transformation.

As we’ve mentioned in recent ACLC newsletters, I will be interviewing CMMI Director Liz Fowler in December for an upcoming Race to Value podcast. This interview will be an important opportunity to emphasize the values of ACLC members and our alignment with the strategic direction of CMMI. Watch for that podcast episode to air in early 2022.

Warm Regards,

Executive Director, ACLC