CMMI rolls out strategic refresh to make payment models more equitable and streamlined

care coordination
The Center for Medicare and Medicaid Innovation released a strategic refresh for how it will develop payment models in the next 10 years. (Getty)

The Biden administration issued a strategic plan Wednesday to make value-based care payment models more equitable and streamlined to foster more participation from providers and patients over the next decade.

Officials with the Center for Medicare and Medicaid Innovation (CMMI) introduced the strategic refresh, which will inform how models are evaluated and crafted by the center over the next decade. Key goals of the refresh include judging the success of models not just on whether they save Medicare money but also whether they improve health equity.

CMMI officials said to expect fewer models in the near future, noting that too much overlap has caused confusion and consternation among providers. Officials also pledged to provide more actionable data and payment flexibility for providers to help entice greater participation.

The center made an ambitious goal by 2030 of all models having multipayer alignment and having all Medicare beneficiaries and most people on Medicaid in some type of accountable care relationship.

The refresh comes after a major review of the more than 50 models CMMI has put out over the past decade. A white paper released by the Centers for Medicare & Medicaid Services (CMS) outlining the strategy found that only six of those more than 50 models generated substantial savings for Medicare.

The sheer number of models helped inform a key pillar of the center’s new strategy: There are too many models.

“We heard from many of you that our models are too burdensome and complex and overlapping models create substantial confusion,” said CMMI Director Liz Fowler during an agency webinar Wednesday outlining the refresh. “Moving forward, we are committed to create a more cohesive articulation of how all the models fit together.”

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She added model parameters need to be more transparent and understood.

Fowler also acknowledged providers’ concerns surrounding “historically complex” financial benchmarks that determined whether they were on the hook for repaying Medicare.

“We need to set benchmarks in the future that balance encouraging participation while sustainably generating savings,” she said.

CMMI’s white paper floated the idea of giving time-limited, upfront funds to smaller primary care practices or providers with limited value-based care experience. The goal is to help them better transition to population-based payments and a total cost-of-care approach, the paper said.

Another concern is that the agency has been too laser-focused on the amount of savings a model generated as opposed to the overall system impact.

“We have not always mined the experience of our models to understand what has really changed,” Fowler said.

CMMI’s statutory authority requires that models provide savings for Medicare, but officials said models going forward will also be judged by whether practices or outcomes can improve the system overall, especially with health equity and lowering out-of-pocket costs for beneficiaries.

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CMS hopes to reach out more to different types of providers, including those that treat underserved populations.

All new models will include patients from historically underserved populations and safety net providers like community health centers and rural clinics, the white paper said. Models could also address areas of inequities such as avoidable hospital admissions.

But what about the models that are still operating?

Fowler said currently there is no decision to end models early due to the strategic refresh. However, the principles will guide any revisions to existing models.

“Where possible current models may be modified, for example, to better address health equity, social determinants of health, include more Medicaid beneficiaries and modify financial incentives to achieve outlined goals,” Fowler said.

The refresh earned early support from several provider groups. 

The National Association of Accountable Care Organizations said that the strategy puts the center on a roadmap to expand value-based care. 

"NAACOS applauds efforts to expanded accountable care for all Medicare beneficiaries," said President Clif Gaus in a statement. "This is a worthy and valuable goal that’s needed to put Medicare spending on a more sustainable path."

But NAACOS cautioned that any strategic refresh needs to also drive more providers to become ACOs. Gaus referenced a decline in ACO participation in the Medicare Shared Savings Program.

"There are fewer ACOs today than any year since 2017, a trend that needs to be reversed," Gaus said.