The CMS Innovation Center, responsible for implementing cost-saving pilot payment models, is choosing to base models it prioritizes off three principles, the department announced May 13.
The principles—promoting evidence-based prevention, empowering people to achieve health goals and ensuring competition—are meant to ensure Innovation Center models move program beneficiaries to accountable care arrangements, limit high utilization and ensure models are “fiscally sound,” the Centers for Medicare and Medicaid Services (CMS) said.
Other goals are to “refine and simplify model benchmarking methodology,” limit state influence in setting rates and mandate alternative payment models involve downside risk—so long as the downside risk is coupled with advanced shared savings or prospective payments.
“As responsible stewards of federal taxpayers’ dollars, the Innovation Center will focus on models that show the greatest promise for generating savings and improving quality,” said Abe Sutton, director of the Center for Medicare and Medicaid Innovation (CMMI) at CMS, in a statement.
In what is becoming a common refrain among top Trump administration health officials, Sutton stressed the rising rate of healthcare expenditures as chronic disease plagues the country. He said a focus on prevention is not easy, but is necessary, and that the food industry’s grip on Americans through ultra-processed foods and sugary drinks must end.
“It might feel like a lot is stacked against us, but if we work together and let our curiosity lead us in fixing these problems, we have a real opportunity to change our health care system and help people stay healthier longer,” he said.
He then turned more hopeful, highlighting the promise to change the system through artificial intelligence breakthroughs, new cell and gene therapies and the rise of digital health. The Medicare Diabetes Prevention Program and the ACO REACH program are two models that should be expanded and replicated throughout other areas of healthcare, he added.
Sutton shared that the department would partner with the private sector and “test improvements” to the Medicare Advantage program, as well as test changes to Medicaid.
New models, expected to rolled out “in the coming months,” could absorb elements of prior primary care, specialty and accountable care organization (ACO) models. Models may also focus on nutrition, tobacco use or cancer screenings.
“There will be opportunities to engage community-based initiatives,” explained Sutton. “Innovation Center models will include prevention and health promotion services and activities that have evidence of improving patient outcomes, such as potentially providing functional and lifestyle medicine interventions to promote physical activity and good nutrition, addressing cardiovascular risk, providing vaccinations, and screening for cancer. This will also include evidence-based activities to slow disease progression, akin to those tested in Innovation Center models focused on kidney disease.”
Other models could give providers the ability to obtain new waivers.
“For instance, we will explore waivers for accountable care entities that assume global risk to provide durable medical equipment (DME) that may bypass National Coverage Determinations if they support transition to or remaining in the home,” Sutton continued. “Other examples are reduced cost-sharing for high-value or preventive services and payments to caregivers to better support those experiencing cognitive or functional decline.”
Though health equity is not mentioned in Sutton’s remarks, better managing chronic conditions is repeated several times. The Innovation Center is evaluating if phone applications or health education tools can be a prominent focus within models to help individual people.
Expect provider payments to be risk-based and advanced payment to be wrapped into quality incentives, the department previewed. A “specialty-focused longitudinal care” model in Medicare Advantage will also be studied.
"One of the most significant barriers to provider adoption of value-based care has been misalignment across payers and programs," said Anne Tumlinson, founder and CEO of ATI Advisory, in a statement shared with Fierce Healthcare. "Providers cannot invest effectively in system change for one program or one payer – we need alignment. Even though the multi-payer strategy is extremely ambitious, it is necessary if we’re ever going to truly transform our healthcare system.”
Providers in rural areas, or those honing in on complex care and specialty populations, may benefit from the changes. New models will likely “expand the use of advanced shared savings and prospective payments” by “collecting losses over longer time periods.”
Sutton’s comments even touched on site-neutral payments, suggesting models could cause services to cost similarly across healthcare settings.
CMS will no longer attempt to transition all Medicare beneficiaries to accountable care arrangements by 2030, Sutton told Modern Healthcare, and the Medicare Advantage Value-Based Insurance Design Model will not return.
Updated: May 14 at 10:04 a.m. ET