Insights^

Advancing health equity is one of the five strategic objectives the CMS Innovation Center (CMMI) outlined in its Strategy Refresh back in November 2021.  It’s no surprise that health equity is becoming an increasingly important goal at CMMI as the Biden administration has made health equity a major priority since day one.

However, CMMI has its work cut out for itself.  According to a July 2022 report, implicit bias is pervasive in at least three payment models, which signals challenges if CMMI is serious about advancing equity.

Implicit bias is an involuntary bias that a person is unaware of.  Often times, negative attitudes and stereotypes can play a powerful role in shaping implicit bias, or “unconscious prejudice.”  Two top CMMI officials authored the report on implicit bias to analyze how implicit bias may be impacting beneficiary groups in payment models. (https://www.firstchoicedentrepair.com/)

In its analysis, CMMI only reviewed three models: the Comprehensive Care for Joint Replacement (CJR) Model, Kidney Care Choices (KCC) Model, and Million Hearts® Cardiovascular Risk Reduction Model.  CMMI selected these models because they represent a microcosm of CMMI models that vary by mandatory/voluntary status, financial methodology, and risk stratification.

Overall, the report found that use of certain risk-assessment and screening tools, provider tools, and payment design and risk-adjustment algorithms has led to the exclusion of some beneficiaries from these models.  Here are some key findings:

• The CJR Model tests bundled payment plans for participating providers that perform knee and hip replacements.  The report found beneficiaries receiving joint replacements were “less medically complex” than those receiving joint replacements at the same hospitals before model participation began.  The report also found that beneficiaries in the model are less likely to be dual-eligible, which indicates a lower socio-economic status.  It is also worth noting that Black Americans are likely to receive knee and hip replacements than White Americans.
• The KCC Model encourages nephrologists, dialysis facilities, and end-stage renal disease (ESRD) practices to focus on the total care of their patients and incentivizes kidney transplants for chronic kidney disease beneficiaries.  The analysis found that the model’s medical eligibility criteria may have inadvertently excluded Black American beneficiaries, despite the fact that Black Americans are over three times more likely to have ESRD.
• The Million Hearts Model provides financial incentives for practices to lower 10-year cardiovascular disease risk for the 30% of high-risk Medicare beneficiaries.  The evaluation found that despite being developed specifically for Black and White populations, the risk calculator used to predict risk scores underestimated risk among patients in other racial and ethnic groups that do not identify as White or Black as well as patients in lower-income households.

CMMI acknowledged that its findings are “troubling” and underscore a need for a “more systematic evaluation of implicit bias in current and new models.”  As a next step, CMMI says it is working on a “step-by-step guide” to detect and address bias in current models and prevent bias from forming in future one.

While it’s encouraging to see CMMI has a plan to address implicit bias, the revelation that unconscious prejudice is prevalent in three key payment models only adds to the list of challenges CMMI needs to address.  According to an August 2021 report, only a handful of CMMI’s 40-plus models have met the center’s statutorily required goal of reducing costs or improving quality.  In addition to the Biden administration’s emphasis on health equity, the report’s findings likely catalyzed CMMI to lay out its strategic refresh in November 2021, which makes reducing costs and improving quality its “overarching goal.”  On top of CMMI’s difficultly of meeting its statutory obligations, the center now faces the challenge of addressing implicit bias, which may also be prevalent in additional payment models.

All in all, CMMI’s issues with reigning in costs, boosting quality, and stopping implicit bias could signal larger structural problems within the center.  Of note, CMMI’s problems are not lost on lawmakers, in May 2022, Sen. Cory Booker (D-NJ) and Rep. Terri Sewell (D-AL) introduced bicameral legislation to require the center to work with experts on health equity when developing and reviewing payment models.

At least CMMI has acknowledged its challenges and is laying out plans to address them, including its strategic refresh and a forthcoming “step-by-step guide” on tackling implicit bias.  However, CMMI won’t be able to solve its problems overnight, and the center has a long way to go if it not only wants to achieve its statutory goals of bringing down costs and enhancing quality, but also take on new priorities like improving health equity.

States Regain Authority to Pay for Home Health Aides’ Insurance 

State Medicaid agencies can once again directly pay for independent home health aides’ benefits, according to a final rule the Centers for Medicare and Medicaid Services (CMS) issued Thursday.  The final rule overturns a 2019 rule that required states to pay the full Medicaid rate to home health aides, which made health coverage and other benefits more costly and created administrative barriers to enrollment.  Under the new rule, state Medicaid agencies can now allow home health aides not working with an agency to have employee benefit premiums and union dues deducted from their paychecks.  According to CMS, boosting benefits for home health workers can help address the industry’s workforce shortage.

FDA Open to Moving Up Meeting Dates on Vaccines for Young Kids

A top Food and Drug Administration (FDA) official told members of the Select Subcommittee on the Coronavirus Crisis during a May 9 briefing that the agency will move up an advisory panel’s meeting dates on vaccines for children under 6 if the FDA finishes reviewing vaccine data sooner than expected.  The briefing was convened after reports emerged that the FDA was delaying its review of COVID-19 vaccines for young kids until both Pfizer and Moderna had submitted clinical trial data.  Additionally, the subcommittee was informed that the FDA would not withhold authorization for a pediatric vaccine solely because it did not reach a 50% efficacy threshold at blocking symptomatic infection, which was previously required for COVID-19 vaccines.  FDA advisory panel meetings on vaccines for young kids are currently scheduled for June 2022.

Administration Officials Still Tight-Lipped on End of PHE

The Biden administration on Tuesday sent a letter to state governors to urge them to make preparations for the end of the COVID-19 public health emergency (PHE).  However, the administration declined to give any indication as to when it will let the PHE expire, although the letter did reiterate the administration’s commitment to provide states 60 days’ notice before pulling the plug on the PHE.  The PHE is currently set to end of July 16, which means the administration would have to communicate that it will let the current PHE end no later than Tuesday, May 17.  Numerous policies tied to the PHE are immensely important to the states, including Medicaid redetermination and telehealth waivers.

Reed Officially Resigns from Congress, Takes Job with Lobbying Firm

Rep. Tom Reed (R-NY) officially resigned from Congress on Tuesday, and he will soon start a new role at Prime Policy Group, a government relations firm.  Reed announced in 2021 that he would not seek an additional term following allegations of sexual misconduct.  In a final floor speech, Reed decried “the current focus on extremism” in politics, and he called for “petty political posturing to end.”  Reed was the top Republican on the Social Security Subcommittee of the powerful House Ways and Means Committee, and Rep. David Schweikert (R-AZ) is likely to replace Reed as the subcommittee’s top Republican.  Reed’s resignation will trigger two special elections this year to determine who will succeed Reed in representing New York’s Southern Tier region in Congress.

ICYMI: Paris Hilton Returns to Washington

This week, media personality and businesswoman Paris Hilton was spotted on Capitol Hill and in the White House, where she advocated for legislation to improve the oversight of youth treatment facilities.  Hilton endured psychological abuse at one such facility as a child, and in October 2021, she shared her experiences while testifying before a Utah State Senate panel.  In April, Hilton’s media company began working with a lobbying firm to advance legislation to regulate congregate care facilities for teens.

Health equity is the latest focus of the Center for Medicare and Medicaid Innovation (CMMI), which was launched a decade ago to develop and test health care payment models with the goal of saving money for Medicare.  This push for health equity goes back to the very beginning of the Biden administration when he first issued an executive order (EO) on advancing health equity in January 2021.  What steps has CMMI taken to push for health equity since then, and how will CMMI pull it off?

CMMI’s shift to health equity kicked off in October 2021, when the center released a white paper announcing a “strategic refresh” that would judge the success of its models not just on whether they save money but also whether they improve health equity.  Of note, the white paper found that only six models of the more than 50 models CMMI currently has generated substantial savings for Medicare.

CMMI followed-up this strategic refresh in February 2022 when it launched the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model, a redesign of the Global and Professional Direct Contracting (GPDC) Model.  A key feature of the ACO REACH model is a requirement for model participants to develop a health equity plan that identifies underserved communities and outlines initiatives to reduce health disparities within their beneficiary populations.

The ACO REACH Model won’t be the last CMMI model to make health equity a cornerstone.  In March 2022, CMMI Director Liz Fowler said creating a health equity plan will  likely be a requirement for future innovation center models.

CMMI took another bold step on health equity in March 2022 when Chief Medical Officer Dora Lynn Hughes announced in a Health Affairs blog post that the innovation center has added “Advancing Health Equity” as one its five strategic objectives.  In the blog post, Hughes outlines ways CMMI intends to achieve this new objective:

• Developing new models and updating existing models to promote and incentivize health equity, as demonstrated by the ACO REACH Model.
• Increasing the participation of safety net providers to ensure models reach underserved communities.
• Increasing collection and analysis of equity data, primarily by coordinating with other offices in the Department of Health and Human Services (HHS).
• Monitoring and evaluating models for health equity impact by analyzing beneficiary experience and equity assessments.

Can CMMI pull off its health equity goals?  After all, only a fraction of the center’s 50 models achieved the goal of saving Medicare money, which makes the center’s capability to tack on and carry out another goal seem overly ambitious.

Fortunately, CMMI has a plan.  In her blog post, Hughes stated that the center will have to collaborate with offices and agencies across HHS, particularly those focused on social determinants of health like food, housing, and transportation.  Outside of the government, Hughes said CMMI is already meeting with groups that have not previously engaged with the center, like community-based organizations and patient advocacy groups, and that CMMI is hosting roundtable discussions on health equity to help inform its work.

On top of this, the Centers for Medicare and Medicaid Services (CMS) is working hard to advance health care interoperability, which CMS Administrator Chiquita Brooks-LaSure said in March 2022 is essential to addressing the “inequities in our health care system.”  Better data collection is one of the four ways CMMI hopes it will achieve its health equity goal, and Brooks-La Sure recently announced that CMS will soon publish a rule on health data exchange.  While CMMI’s success at creating models that reduce Medicare costs may be limited at best, the center has laid out some specific actions it hopes to take to achieve its new goal, increasing the odds this goal can become reality.

CMS Issues Narrow Coverage Determination for New Alzheimer’s Drug

On January 11, the Centers for Medicare and Medicaid Services (CMS) proposed a national coverage determination for Alzheimer’s disease medication Aduhelm that will limit Medicare coverage to patients participating in relevant clinical trials.  The Food and Drug Administration (FDA) approved the Biogen-developed drug last year, despite conflicting data regarding the drug’s efficacy.  Aduhelm attracted significant controversy after Biogen announced a launch price of $56,000, which was later halved due to public outcry.  CMS is holding a 30-day public comment period and will announce its final decision by April 11.

Supreme Court Blocks Vaccine Mandate for Employers, but Not Health Care Providers

On Thursday, the Supreme Court struck down the Occupational Safety and Health Administration (OSHA) mandate for private sector employers to require workers to be vaccinated or regularly tested, on the basis that OSHA lacks the authority to “regulate public health more broadly.”  The high court’s vote to invalidate the vaccine mandate was 6-3, along ideological lines.  However, the Supreme Court did vote to uphold a CMS regulation that requires health care provider that receive money from the federal government to mandate that employees be vaccinated.  According to the majority opinion, CMS was justified to mandate vaccinations because unlike OHSA, the agency has long-standing authority to issue health care mandates.

Sinema Doubles Down on Opposition to Filibuster Reform

Sen. Kyrsten Sinema (D-AZ) strongly expressed her opposition to changing filibuster rules to pass a voting rights bill in an impassioned speech she delivered on the Senate floor yesterday.  While Sinema said she supports the Democrats’ voting rights legislation, she’d prefer to see it advance through more collaboration between Democrats and Republicans.  Sinema’s speech came just before President Joe Biden met with Senate Democrats on Capitol Hill in order to stir up support for voting rights reform.  Both Sinema and her West Virginia Democratic colleague Sen. Joe Manchin’s continued opposition to creating a filibuster carve out for the voting rights bill means Democrats’ hopes of passing the measure are facing an uphill battle and may not get done.

Johnson Announces Reelection Bid, Perlmutter Announces Retirement

In a Wall Street Journal op-ed, Sen. Ron Johnson (R-WI) announced on January 8 his plans to run for a third term in the Senate, putting an end to months of speculation regarding his plans.  Johnson initially pledged in 2016 to not seek reelection in 2022; however, encouragement from constituents and the nation’s “unsustainable path” caused him to reconsider.  The Senate race in Wisconsin is expected to be close, as President Biden narrowly won the state in 2020.  Later in the week, Rep. Ed Perlmutter (D-CO) announced that he will not be seeking reelection in November.  Representing the north and west suburbs of Denver, Perlmutter served in the Colorado Senate for eight years before his election to Congress in 2006.  In a statement, Perlmutter said he is stepping aside to “explore other opportunities,” but did not specify what those would be.

ICYMI: Harry Reid Lies In State at US Capitol Building

On Wednesday, former Senate Majority Leader Harry Reid (D-NV) lied in state in the Rotunda at the US Capitol, where President Joe Biden, Vice President Kamala Harris, and dozens of other elected officials paid tribute.   Reid, who worked as a Capitol Police officer while studying law at George Washington University, served for years in the Nevada state government before being elected to the House in 1982 and the Senate in 1986.  Reid’s 30-year Senate career included a decade as Majority Leader, during which he led the Democratic caucus in voting to end the filibuster for most presidential nominations, including federal judges.  Reid retired in 2017 but continued to stay active in the public eye despite his diagnosis of pancreatic cancer in 2018.

Open enrollment for 2022 kicked off on November 1, and it’s particularly consequential to President Joe Biden, who campaigned on building off the success of the Affordable Care Act (ACA) to expand access to health care coverage.  To deliver on these promises, open enrollment has undergone several key changes to make it more consumer-friendly for 2022.

• First off, open enrollment is a month longer than the previous four years.  While open enrollment last year ended on December 15, 2021, for the upcoming plan year, it ends on January 15, 2022.
• Plan enrollees can also expect record-low prices, thanks to an extension of ACA premium tax credits made possible by the American Rescue Plan.  According to the Biden administration, four out of five people can now find a plan for $10 or less per month.
• Additionally, 2022 sees a major boost to enrollment assistance.  Plan enrollees for 2022 can now look forward to over 5,000 enrollment assisters and navigators, plus nearly 50,000 brokers and agents.  Notably, the Centers for Medicare and Medicaid Services relaunched a program that engages with local organizations to provide outreach and education.
• The current open enrollment has a new focus on health equity.  The administration is rolling out new efforts to people who previously lacked access to coverage, and advertising is being conducted in several new languages: Chinese (Mandarin and Cantonese), Korean, Vietnamese, Tagalog, and Hindi.
• Finally, more Americans than ever will be eligible for open enrollment 2022.  That’s because three states (Kentucky, Maine, and New Mexico) transitioned from state-run coverage to the federal exchange for 2022, bringing the total number of state-based marketplaces on healthcare.gov to 18.

What Do These Changes Mean for Enrollment?

For plan year 2021, enrollment reached a record high of 12.2 million people, which can be attributed to a special COVID-19 enrollment period that ended in most states in August 2021.  However, many Americans seem to be unaware of premium tax credits made possible by the American Rescue Plan.  According to an October 2021 poll by the Kaiser Family Foundation (KFF), only about a quarter of adults who are uninsured or buy their own insurance checked to see if there were eligible for ACA premium tax credits.

KFF currently estimates that nearly 11 million Americans are eligible for but not enrolled in subsidized ACA plans.  Despite a record number of enrollees in 2021, it remains to be seen if new outreach efforts, longer enrollment periods, and other changes brought into play for 2022 will be enough to attract more enrollees and continue to lower the number of uninsured individuals in America.