CMS's Innovative Care Delivery Models
With "bending the cost curve" as central theme, much of US health care eco-system continues to evolve its approach towards containing costs while delivering quality care. This evolution is happening in different ways using experimentation but many technology breakthroughs have overshadowed such progress. One such experiment has quietly unfolded in the past decade.
CMS's Innovation Center
The US Healthcare financing is notoriously complex. With Fee For Service mostly prevalent in commercial and employer space, cost and quality of care is never focused as much as it is when it comes to government sponsored health care.
As America's largest healthcare payer, Centers for Medicare & Medicaid Services (CMS) has taken a unique and innovative approach in driving value for care delivered. CMS designed CMS Center for Medicare and Medicaid Innovation (the Innovation Center), aka (CMMI) to find new ways to pay for, deliver and improving care while keeping costs lower. We heard this many times, but CMMI is the one experimenting and executing this concept across variety of care modalities.
The Innovation Center lays groundwork to setup resources, identify, develop, rapidly test and encourage widespread of innovative care and payment models to achieve Better Care, Healthier People, Smarter Spending.
This Innovation center tests, what it calls, Alternative Payment Models (APMs) which are ideas turned into models that rewards providers for delivering high quality, coordinated care for all Americans. The popular categories in such payment models are Accountable Care, Disease specific, Episode Based, Health Plan, Prescription Drug, State and community based, Statutory Models.
How do Ideas turn into Models ?
Forming and designing these models do not happen in isolation. Model ideas are informed by Health care research and outside experts, Public health needs, CMS’ and the administration’s strategic priorities and input from interested parties. An idea goes through through four phases of transformation Formulation, Vetting and Selection, Building, Implementation and Evaluation, before it turns into a viable Model.
Models participants are state based Medicaid exchanges, healthcare provider groups/organizations, care delivery organizations that receive tools and resources to help them implement models and achieve the model's goals. These innovative payment and care delivery models are not necessarily atypical Randomized Clinical Trials (RCTs).
Which Models are suitable for experimentation ?
Model ideas do not take specific technology into account. Model ideas are vetted with evidence and research that determine that the underlying idea holds promise for improving quality of care and reducing burden and expenditures while meeting the statutory requirements for 1115A of SSA Act. Broadly, the selected models align with the five strategic objectives Drive accountable care, Advance health equity, Support innovation, Address affordability, Partner to achieve system transformation
Impact and Feasibility
Core elements of the measuring a model lies in its 1) diversity of pushing innovation to a specific healthcare, provider type or patient population, 2) anticipated reach and 3) potential for health system transformation while accounting for its feasibility towards it being operational, evaluative, scalable.
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Implement and Measure
As these are experimental models, the usual testing cycle is between 5-10 years. Some models vary in the duration depending on the necessity. This evaluation will determine if there is promise in expanding these to future years and larger participants. Participants also have flexibility in achieving these goals. The results of the evaluation will influence CMS decisions changes to the policy and inform future model ideas.
Tested and Proven Models
One example of Proven Model is Medicare Shared Savings Program (MSSP), an accountable care model. Initially tested by CMMI, it has since become a permanent part of Medicare, with over 480 ACOs participating as of 2024, serving more than 11 million beneficiaries.
Another proven and expanded example is the Bundled Payments for Care Improvement (BPCI) Advanced model, an episode-based payment model that has shown promise in reducing costs and improving care coordination for specific procedures and conditions
While there are many active and thriving models currently in operation, there have been some recently withdrawn models like Community Health Access and Rural Transformation (CHART) Model which served their purpose of informing policymakers of making adjustment to future rural health care models.
And new models like Innovation in Behavioral Health (IBH) Model, Transforming Maternal Health (TMaH) Model, and Guiding an Improved Dementia Experience (GUIDE) Model represent expanded focus towards under appreciated specialty care that has become evident from the past experiments combined with fast growing disease burden caused in the shifting demographics.
Final Thoughts
CMMI's innovative payment models showcase CMS's unwavering commitment to improve healthcare by reform. Not all models are designed to succeed and one can argue that this approach could result in wasted resources and funding when they don't work. But as Brene Brown once said "There is no innovation and creativity without failure. Period.” And CMS's stands by this quote more than anyone.
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