CMS

Implicit Bias Is CMMI’s Latest Problem to Tackle

by Matt Gontarchick

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.

CMS

Tracking CMMI’s Shift to Health Equity

by Matt Gontarchick

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

CMS Puts Geo Model on Hold

by Matt Gontarchick

On March 1, the Center for Medicare and Medicaid Services (CMS) announced its Geographic Direct Contracting Model is “currently under review” until further notice.   While CMS has yet to provide a reason for the pause, criticism from industry stakeholders and the new Center for Medicare and Medicaid Innovation (CMM) Director may explain the pause.

Announced in December 2020, the Geographic Direct Contracting Model, or the “Geo Model,” envisions using direct contracting entities (DCEs) to build integrated relationships with health care providers and coordinate care for Medicare beneficiaries in designated geographic regions.  The model, which had been under development for two years, builds on lessons learned from the Next Generation ACO model, Medicare Advantage, and other initiatives.

However, the Geo Model is the only CMMI model that has been paused by the new Administration so far.   In the absence of an official justification from CMS, one of the reasons why the model may have been put on hold was criticism from health care stakeholders.  In a December 2020 letter to then-CMMI Director Brad Smith, the National Association of ACOs warned the model could generate confusion among beneficiaries over who is compelled to participate.  Additionally, the Center for Medicare Advocacy urged the then-Biden Transition Team in a December 2020 letter to halt the Geo Model due to uncertainty over how the model would work with other forms of insurance such as Medigap.

The move to suspend the Geo Model is not entirely without precedent.  The Biden Administration paused or withdrew numerous actions by the previous Administration since assuming power, which is typical for new presidential administrations.  For instance, CMS has withdrawn proposed rules on oversight for accrediting organizations, revisions to dialysis coverage requirements, and changes to Medicare Part A enrollment requirements since January 20. 

It should be noted that not all stakeholders oppose the Geo Model.  In a March 4 letter, America’s Physician Groups urged CMMI to restart the model as soon as possible due to “extensive financial investments” participating providers have already made in preparation for the model’s launch, as well as a genuine belief that the model represents a meaningful shift away from the fee-for-service model.

In addition to external criticism, pressure to put the Geo Model on hold may have come from within CMMI itself.  Recently, the Biden Administration tapped Liz Fowler to serve as CMMI Director.  Prior to her new leadership role at CMS, Fowler served as Executive Vice President for Programs at the Commonwealth Fund, where she co-authored a December 2020 blog post about the Geo Model.  While the blog post largely served as an explainer for the model, it raised several questions, including how CMS would be able to produce savings CMS had projected and whether CMS is adequately tracking beneficiaries’ use of services under the model.

Thus, pressures from both inside and outside CMS have likely led to the Administration’s decision to suspend the model for the time being.  That said, while not knowing yet where CMMI may take the geographic-based care and payment model, it certainly seems possible that the Administration could choose to pause other CMMI models in the future.