Strategy Refresh and the Model Lifecycle
- How has external input been incorporated into the development and implementation of the Innovation Center’s strategic refresh?
Beginning in the spring of 2021, the CMS Center for Medicare & Medicaid Innovation (the Innovation Center) engaged with subject matter experts across multiple fields and completed a literature review on what those experts see as the greatest needs for our health care system. The Innovation Center also consulted with experts in other components of CMS. Beginning in late 2021, the Innovation Center started hosting a series of listening sessions to continue to gather additional feedback on the implementation of the strategy. We also gathered perspectives from patients, consumer advocates, payers, health care providers, hospital leaders, academics, thought leaders, accountable care organizations, conveners, and technology experts. In addition to individual outreach, the Innovation Center conducted market research with providers and health administrators, and with beneficiaries and caregivers, to gain a greater understanding of their priorities and what they perceive as obstacles to value-based, person-centered care.
- What types of models will the CMS Innovation Center be introducing as a result of the Strategy Refresh?
The CMS Innovation Center will be focused on model types that drive transformation and that help the CMS Innovation Center achieve its vision of a health system that achieves more equitable outcomes through high quality, affordable, person-centered care. Types of models may include:
- ACO model tests that create accountability for total cost of care and outcomes
- Advanced primary care model tests
- Specialty model tests that support integrated, whole-person care
- State total cost of care model tests
The CMS Innovation Center is committed to not only introducing new models, but to engaging with stakeholders, increasing data transparency, and health care transformation in defining their success.
- In addition to introducing new models, will the CMS Innovation Center be engaging in other activities or initiatives as a result of the Strategy Refresh?
The CMS Innovation Center is committed to introducing new models and executing on activities and initiatives that can improve current and future models. These new initiatives include increasing data access and transparency for better insight into model performance, incorporating social determinants of health (SDoH) screening and referrals into model design, collecting health equity data in models, improving approaches to benchmarking and risk adjustment, and increasing multi-payer alignment, beneficiary engagement, and the use of patient-reported outcome measures in models. The Innovation Center will engage with stakeholders on new models and cross-cutting initiatives as they are being developed.
- How does the strategy refresh affect models? Does the CMS Innovation Center intend to launch new models? Does the CMS Innovation Center intend to end existing models early?
The five objectives of the strategy refresh will guide revisions to existing models as well as consideration of future models. Where possible, current models may be modified to better address health equity and social determinants of health, to include more Medicaid beneficiaries, and to modify financial incentives to achieve outlined goals. Existing models may also benefit from greater innovation in payment waivers. The Innovation Center will continue to launch new models, but they will be streamlined and more harmonized. By launching more harmonized models and better measuring and defining how models impact health system transformation, the Innovation Center can identify what works and appropriately scale best practices to affect lasting change for beneficiaries and the U.S. health system.
- How does the CMS Innovation Center plan to redefine success of a model?
The CMS Innovation Center remains committed to its statutory mandate to reduce costs and improve quality. Improving quality will require consideration of impacts on health equity, person- centered care, and health system transformation – efforts which are aligned with CMS-wide goals.
- Does the CMS Innovation Center plan to renew successful prior models or introduce additional opportunities for successful participants in prior models?
The CMS Innovation Center’s overarching goal will continue to be expansion of successful models that reduce program costs and improve quality and outcomes for Medicare and Medicaid beneficiaries. The lessons learned over the first decade of the CMS Innovation Center have provided a wealth of knowledge to inform future model design and to reassess current models in light of the strategic refresh. The CMS Innovation Center strongly encourages participants in previous models to engage in current and future model opportunities as they become available. We also welcome input from both model participants and those that have not yet participated in models to increase the reach of our models to more beneficiaries.
- How will the CMS Innovation Center use information on past model success to influence future model development? What role, if any, will learning play into model effectiveness?
The Innovation Center’s portfolio of model tests has yielded important lessons over the last ten years. For example, the ACO Investment Model (AIM), which demonstrated the value of advancing payments to support new ACOs in rural and underserved areas, is informing current and future ACO model design concepts. Future ACO efforts will incorporate lessons learned from other models, including bundled payment models, to drive coordinated and efficient care. The review of past and current models (as discussed in the white paper) has identified opportunities to broaden participation among practices, to reach more beneficiaries, and ensure sound financial methodologies with refined benchmarking and risk adjustment.
- How is the CMS Innovation Center collecting feedback from patients and caregivers to inform our models?
The CMS Innovation Center is seeking input from patients, caregivers, and consumer advocates. This feedback will be used to identify those topics and issues that are most important to patients and caregivers.
The Innovation Center recognizes that patients and caregivers do not experience the health care system through the lens of models, but rather through their relationships with their health care providers. The Innovation Center seeks to prioritize those issues that can meaningfully impact how patients and caregivers experience care and achieve improved outcomes. This includes time spent with, and communication with, the health care providers, as well as support or referrals to address health-related social needs.
The Innovation Center is also interested in capturing information related to patient, family and caregiver experience. This includes holding listening sessions on topics that matter to patients and caregivers, expanding our measurement and evaluation strategy to assess caregiver experience and outcomes, and engaging with caregiver-focused organizations to receive feedback and input on Innovation Center models. For example, the Innovation Center held a listening session to understand patient and caregiver experiences with serious illness care in general, and their experiences with recent changes in care delivery. The Innovation Center uses feedback such as this to identify gaps across the model portfolio and strengthen existing models to better support patients and caregivers.
Advancing Health Equity
- What are the definitions of health equity and underserved communities?
Health equity is defined as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of
health and health care disparities” (Source: Healthy People 2030). The term “underserved
communities” refers to populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life (Source: Executive Order 13985).
- How will the CMS Innovation Center support model participants to better care for underserved populations?
Health equity is fundamental to health care transformation, and the Innovation Center is taking steps to improve beneficiary experience and health outcomes for populations defined by race and ethnicity, geography, socioeconomic status, disability, sexual orientation and gender identity, and other factors. The Innovation Center supports multiple learning activities with participating providers on providing culturally competent care and will offer targeted learning opportunities for model participants to advance health equity, including sessions focused on reviewing best practices and different approaches to take when collaborating with community partners to address social needs. The CMS Office of Minority Health also offers resources such as A Practical Guide to Implementing the National CLAS Standards and Providing Language Services to Diverse Populations: Lessons from the Field on culturally and linguistically appropriate services (CLAS).
- Why is the CMS Innovation Center collecting demographic and Social Determinants of Health Data in its models?
CMS is working to advance health equity by designing, implementing, and operationalizing policies and programs that support health for all the people served by our programs, eliminating avoidable differences in health outcomes experienced by people who are disadvantaged or underserved, and providing the care and support that our enrollees need to thrive. In line with this vision, the Innovation Center needs to ensure the models it is testing are accessible to, and therefore inclusive of, all applicable subpopulations of beneficiaries. This will help to ensure that evaluation results from the Innovation Center’s models are generalizable and will provide additional data points to assist CMMI in making informed decisions as to whether expanding the scope and duration of a model under section 1115A(c) of the Social Security Act is warranted.
- Why is the CMS Innovation Center looking at demographic and Social Determinants of Health Data in monitoring activities for its models?
To monitor the performance of model participants with respect to beneficiary access and quality of care, including making sure that participants are not inhibiting beneficiaries from obtaining the coverage and payment for services available under their Medicare or Medicaid coverage, the Innovation Center has also determined it necessary to require model participants to collect and submit sociodemographic data. This data collection for purposes of model monitoring activities helps to ensure equitable access and treatment is provided to all applicable sub-populations of beneficiaries in Innovation Center models. This is particularly important in models such as the ACO Realizing Equity Access and Community Health (REACH) Model, where beneficiaries with Traditional Medicare retain all of their rights, coverage, and benefits, including the freedom to see any Medicare provider.
- How will the CMS Innovation Center measure success in terms of health equity given limited demographic and SDOH data?
The CMS Innovation Center has been using available data and proxies (e.g. dual eligibility and area deprivation index) to evaluate the reach of existing models in underserved communities and their impact on health equity. Additionally, CMS is identifying opportunities to increase the emphasis of health equity in its existing models, including collecting demographic data from model participants to inform monitoring and evaluation. Moving forward, new model designs will incorporate health equity into their quality strategies and utilize tools specifically designed to screen for social need and social determinants of health, such as the Accountable Health Communities Model Health-Related Social Needs Screening Tool.
Further, in partnership with The Office of the National Coordinator for Health Information Technology (ONC), CMS plans to align participant reporting with the United States Core Data for Interoperability (USCDI) Version 2 requirements for demographic and social needs data. CMS is also working to identify other sources of demographic data that may be available from federal partners where feasible, in a way that is consistent with the Privacy Act System of Records Notices for these data sources and ensures compliance with HIPAA and other applicable laws.
- How will the CMS Innovation Center ensure that the collection of patient-reported outcome measures does not exacerbate existing health disparities due to access, technology, literacy, or language?
The Innovation Center has multiple strategies to ensure the use of patient-reported outcome measures does not exacerbate health disparities. The Innovation Center aims to select measures that have undergone robust testing in a diverse sample of patients, and that take into account different levels of literacy needed to understand the questions included in the measure. The Innovation Center prioritizes measures that can be offered in multiple languages (e.g., CAHPS), include different communication preferences, such as telephone, postal mail, and/or electronic platforms, and do not require significant time or resources on the part of the patient to complete.
As described in the Innovation Center’s 1-year status update report on its Strategy Refresh, the Innovation Center is also actively identifying and considering strategies to use quality measures to monitor and address disparities in care and outcomes. Some of these strategies include using quality measures that can provide insight into factors influencing health equity (e.g., screening for health-related social needs), stratifying patient-reported measures by key patient characteristics (e.g., dual eligibility status) or geographic markers (e.g., area deprivation index (ADI)), and sharing information with providers so they can implement strategies to minimize identified disparities. The Innovation Center also works with other components at CMS such as the CMS Office of Minority Health and the Center for Clinical Standards and Quality (CCSQ), to align on strategies for using patient-reported measures and other quality measures to identify and address disparities.
Strategic Objectives and Model Strategies
What does the CMS Innovation Center mean by accountable care?
In an accountable care arrangement, a group of health care providers, such as primary care doctors, specialists, and hospitals, team together to take responsibility for providing coordinated and high- quality care for patients. They do so by agreeing to be accountable for the quality and overall costs of care for their patients. Advanced primary care and accountable care models (such as those with accountable care organizations) are central to driving growth in the number of beneficiaries in accountable care relationships.
How does the CMS Innovation Center define “person-centered care”?
The CMS Innovation Center defines “person-centered care” as integrated care delivered in a setting and manner that is responsive to the individual and their goals, values and preferences. “Integrated care” is defined as health care services that address patients’ physical, mental, behavioral, and social needs.
Person-centered care includes:
- Care that is guided and informed by patients’ goals, preferences, and values• Using patient-reported outcomes to measure impact
- Integrated and coordinated care across health systems, providers, and care settings
- Managing chronic and complex conditions
- Relationships between patients and providers that are built on trust and a commitment to long-term well-being
For more information about person-centered care and other key concepts, visit: https://innovation.cms.gov/key-concepts.
- How will care innovations/provider tools lead to more person-centered care?
The CMS Innovation Center understands that the success of person-centered care hinges upon significant integration and coordination across provider types and care settings. Person-centered care will be supported by a number of innovations and tools, such as:
a. Payments that incentivize providers to address patients’ social determinants of health, and ultimately, lower total cost of care while maintaining or improving quality of care
b. Payment waivers and other flexibilities that support the provision of care in patients’ homes, community settings and via telehealth
c. Accelerated data-sharing and seamless information exchange to promote care coordination and case management, reduced administrative burden and the diffusion of best practices
CMMI models will also utilize a person-centered strategy when selecting quality measures that matter most to patients. This will likely entail uptake of patient-reported outcomes measures and provide beneficiaries greater opportunities for feedback on their care experience.
- What does the CMS Innovation Center plan to do regarding Medicaid?
The CMS Innovation Center, in collaboration with other CMS components and state Medicaid agencies, will work to address gaps in Medicaid beneficiaries’ care. The CMS Innovation Center models to date have been largely Medicare-oriented, and voluntary models have primarily drawn only those health care providers and organizations with resources and capital to apply and participate, resulting in limited inclusion of Medicaid and safety net providers. In order to increase Medicaid beneficiaries’ access to person-centered care, new models will be designed to include Medicaid as an aligned payer or primary focus.
- What are patient-reported outcome measures and how will they be included in models?
Patient-reported outcome measures are those measures where data comes directly from the patient, and they can be used to capture the patient perspective on key concepts such as health-related quality of life, symptoms or burden of disease, and experience of care. In an effort to collect patient-reported data representing different aspects of patient care, model teams aim to select patient-reported outcome measures that represent different domains from the Center for Medicare and Medicaid Services’ (CMS) Meaningful Measures 2.0 framework.
The quality aims for the model’s target patient population influence the selection of specific patient-reported outcome measures. If a model aims to improve overall health and well-being for a broader patient population (e.g., primary care patients), a more general patient-reported outcome measure may be selected (e.g., global health-related quality of life). If a model aims to improve the outcomes of care for a narrower patient population (e.g., patients receiving treatment for cancer), a condition-specific patient-reported outcome measure may be selected (e.g., cancer-related pain intensity). Patient-reported measures of care experience (e.g., the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey) are also frequently included in models to provide insight into patients’ experiences interacting with providers under the model.
- How will the Innovation Center minimize the burden that collection of patient-reported outcome measures may place on patients and providers?
The CMS Innovation Center recognizes that collecting patient-reported outcome measures has the potential to increase patient, caregiver, and health care provider burden. Measure selection is guided by the goal of minimizing patient and provider burden through the creation of a model measure set that includes enough measures to discern quality of care under the model, but not so many that it places a significant burden on patients or model participants. To minimize such burden, model teams consider and include patient-reported outcome measures in models that have the potential to provide the most meaningful insight into patient health, well-being, and experiences with health care.
When designing models, Innovation Center model teams also strive to include flexibilities that allow model participants to leverage existing capabilities (e.g., electronic medical record platforms) to implement patient-reported measures. There are also opportunities for model participants to build up capabilities, and technical assistance is frequently offered to facilitate effective collection and use of patient-reported outcome measures. Further, the Innovation Center regularly gathers external input to identify opportunities to use new measures or technologies to help minimize the burden of collecting quality measure data. Finally, the Innovation Center actively engages with other CMS components on measure alignment initiatives to reduce variability in the quality measures and reporting requirements used across CMS, thus streamlining the number of measures used by providers and reducing burden.
How will the CMS Innovation Center encourage and support more health care providers to participate in models?
The CMS Innovation Center will work with providers to understand obstacles to participation and develop ways to mitigate those barriers. For instance, after extensive dialogue with a variety of provider communities about possible barriers to participation, CMS is reconsidering how financial incentives in its models are designed to ensure broader, meaningful provider participation. The Innovation Center is also examining additional payment waivers and other flexibilities in Medicare to allow providers to flexibly deliver the care their patients need. CMS also will be assessing current participation requirements with an aim to reducing the administrative burdens on participating health care providers. By understanding barriers—and facilitators—to participation in value-based payment models, we can ensure that future models’ designs are inclusive of a variety of providers that care for underserved populations, ultimately increasing beneficiaries’ access to high-quality care.
How will the CMS Innovation Center improve models for participants?
The CMS Innovation Center will aim to improve the experience of both model participants and the beneficiaries they serve by addressing model overlaps, simplifying model requirements, and reducing administrative burden. To create a cohesive strategy for models, CMS will utilize a hierarchy of models to better address instances of overlap. Further, we will make model parameters, requirements, and other critical details as transparent and easily understandable as possible for participants. The CMS Innovation Center will improve data-sharing with providers and the diffusion of lessons learned to support care delivery, that complies with HIPAA and other applicable laws.
Additionally, we will look for opportunities to integrate health equity into existing models in an effort to increase beneficiary access to value-based care and meet CMS Innovation Center’s overarching strategic goal to realize a health system that achieves equitable outcomes through high quality, affordable, person-centered care.
How will the CMS Innovation Center support primary care practices transition to value-based care?
The CMS Innovation Center continues to be dedicated to developing and testing primary care models. Previous models have tested advanced primary care across the country to improve and enhance how practices deliver care. The Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) models, for example, gave practices the opportunity to deepen their capabilities to deliver comprehensive and coordinated primary care, assuming risk, and using data for continual quality improvement.
Advanced primary care and other accountable care models are central to driving growth in the number of beneficiaries in accountable care relationships. The CMS Innovation Center is interested in hearing from primary care providers about the support they may need to make the transition to value-based care. In addition to the initial Strategy Refresh webinar, the Innovation Center will be hosting additional Listening Sessions to hear more from providers about current barriers and obstacles to participation.
How does the CMS Innovation Center see the current continuum of providers (e.g. those other than physicians) fitting into new models?
The Innovation Center recognizes the value of care teams and a diverse healthcare workforce to improve access, quality, and outcomes for beneficiaries. The key feature of accountable care is to give participating providers the incentives and tools to deliver high-quality, coordinated, team-based care that promotes health, thereby reducing fragmentation and costs for beneficiaries and the health system. For example, the Innovation Center’s advanced primary care models have historically included a range of primary care practitioners to support the delivery of team-based care, including Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), and Physician Assistant (PA). The recently announced ACO Realizing Equity Access and Community Health (REACH) Model includes a new benefit enhancement to increase the range of services that may be ordered by Nurse Practitioners to improve access to care. The Innovation Center will continue to examine ways for current and new models to include providers that can increase access to high-quality care.
- How do I provide feedback to the CMS Innovation Center about the strategy and models?
The CMS Innovation Center is dedicated to engaging with stakeholders and offering opportunities for collaboration in order to test innovative payment and service delivery transformation to inform transformative change in health care. Your insight helps us to learn more about innovations in the field and further our understanding of communities’ evolving health care needs. To learn more and share your feedback, we encourage you to explore the following resources:
a. Feedback can be submitted directly via email to CMMIStrategy@cms.hhs.gov.
b. The CMS Innovation Center website offers details on all CMS Innovation Center models, including current participant geographic and contact information, as well as evaluation reports. Additionally, the CMS Innovation Center Strategy webpage provides resources and updates on pertinent to the Innovation Center’s strategy.