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.
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.