CMMI Director Liz Fowler: Expect advance primary care, total cost models to be released in 2023

The Biden administration is planning to release three to four new payment models on advance primary care and another enabling states to assume the total cost of care for Medicare, a top official shared. 

Center for Medicare and Medicaid Innovation (CMMI) Director Liz Fowler, Ph.D., detailed the center’s plans for this year during the Value-Based Payment Summit on Monday. The three to four new models on advance primary care planned to roll out this year are part of a larger effort by the center to increase the ranks of specialists in value-based care. 

“There’ll be a focus on financial calculations and make it possible for more safety-net providers to participate,” Fowler said. “We will continue to focus on addressing health equity.”

In addition to the new models on advance primary care, the center is planning to roll out a new model that enables states to manage the total cost of care. 

The model will likely be similar to a partnership between the Centers for Medicare & Medicaid Services (CMS) and Maryland that established a global budget for certain state hospitals to reduce Medicare spending and improve quality. The budget was created to incentivize hospitals to get rid of unnecessary hospitalizations. 

CMMI has lauded Maryland’s Total Cost of Care Model as one of the models that have generated significant savings. A review performed by the Trump administration found it did better than other models surrounding bundled payments for total episodes of care like joint replacements. 

Fowler did not specify how many states would be affected by the new cost-of-care model but said that “input from state and constituencies at the state level will be critical.”

How the model results will be evaluated is also expected to change this year. CMMI has authority under the Affordable Care Act to change how Medicare pays for services, and a model has to be certified to be expanded in scope. 

Fowler cautioned that certification can be a “narrow definition of success.”

“We’re developing a framework for judging impact based on the notion of health system transformation,” she added.

The goal is not just to determine whether a model meets certain spending and quality criteria but also whether it contributes positively to a health system’s transformation. 

“The outcome might be a recommendation for Congress for consideration in future legislation or incorporation of key elements into aspects of Medicare or Medicaid,” Fowler said. 

CMS has adopted several reforms aimed at incentivizing participation in value-based care models, especially among safety-net providers. Some of the reforms include upfront investments to help new providers defray initial costs. 

Fowler also touted the start of the ACO REACH payment model that offers full and partially capitated payments to physicians for meeting certain benchmarks. In a first for CMMI, the model includes an adjustment to benchmarks based on how well the provider does in addressing health equity. 

“We’re paying close attention to the equity design elements with the intention of scaling features that work and learning from challenges,” Fowler said.