CMMI’s Strategy Refresh: What Hospices Need to Know

The Center for Medicare & Medicaid Innovation (CMMI) in October announced a “strategy refresh” that would guide development of its future payment models. If executed effectively, the strategy could make a substantial difference in hospice and palliative care as well as the health care system at large, a trio of experts told Hospice News. 

The pillars of this strategy were diversity, equity and inclusion; aligning more patients with accountable care entities; integrated, person-centered care; health care affordability and development of partnerships to achieve these aims.

Among CMMI’s objectives, the diversity and equity piece may be the most significant. Racial, ethnic and socioeconomic disparities are pervasive throughout the health care system, including the hospice space. In 2018, for example, more than 80% of hospice patients were caucasian, according to the National Hospice & Palliative Care Organization (NHPCO). Disparities also exist when it comes to hospice referrals and quality of care.

According to CMMI, every new model will require participants to collect health equity-related demographic data, including information on social determinants of health and barriers to access.

“The focus on equity is going to be critically important. That was the piece in the refresh where CMMI was most specific in their intention to do certain things,” said Davis Baird, director of government affairs for hospice at the National Association for Home Care & Hospice (NAHC). “It’s really hard to address those fully if you don’t have a clear picture into patients and families who are going through those challenges, and the foundation of that is good data.”

The Affordable Care Act established CMMI to test innovative payment and service delivery models to reduce federal expenditures and improve the quality of care. These include programs such as Medicare Advantage, the Medicare Care Choices Model, Primary Care First and direct contracting. The center is a component of the U.S. Centers for Medicare & Medicaid Services (CMS). 

CMMI undertook an internal review of its first decade of work and consulted external researchers and experts as it developed its new approach. For the diversity piece, CMMI seeks to increase participation in value-based care programs of providers who care for underserved populations.

The center also indicated that it would work to ensure that all beneficiaries of CMS programs have access to providers who are improving care quality by addressing issues such as implicit bias in its model design, implementation and evaluation. This could include the launch of more Medicaid-focused models or modification of existing models, as Medicare-based initiatives rarely penetrate its safety net counterpart.

CMMI indicated that it would require a more deliberate and consistent approach to quality measurement to assess the impact of payment and care delivery models on underserved populations.

“There really isn’t innovation without acting in a way that’s going to make the health system more equitable and accessible. The lens through which we should view the ways we want to reform the Medicare benefit is in a way that moves it towards a direction of being more equitable,” Edo Banach, president and CEO of the NHPCO told Hospice News. “That’s probably the most important aspect of the new strategy.”

Banach previously served as senior advisor and deputy director of the CMS Medicare-Medicaid Coordination Office.

Following passage of the ACA in 2010, CMMI replaced the CMS Office of Research, Development, and Information (ORDI). ORDI would test models and present the results to Congress, which then had the option to change health care policy, Sachin Jain, M.D., CEO of SCAN Health Plan, told Hospice News. ORDI programs included examination of diagnosis-related groups as well as prospective payment systems for home health care.

CMMI is different from ORDI in two key ways, Jain said. The first was that CMMI has some money behind it — $10 billion in renewable funds every 10 years. In addition, the U.S. Secretary of Health & Human Services (HHS) had the ability to introduce new payment policies based on CMMI demonstrations.

CMMI has tested more than 50 models since its inception. Only six of these have become permanent to date.

“One of my big concerns with CMMI is that sometimes people prematurely declare failure for something that could potentially be a real lever for actually improving quality and reducing costs,” Jain said. “We, the American public, have to demand more of CMMI in terms of revolutionary cost savings. I think the folks who are in place [at CMMI] are thinking exactly along the right lines, while also integrating components like health equity.”

In addition to work in the private sector and academia, Jain was senior advisor to former CMS Administrator Donald Berwick during the Obama administration and served as CMMI’s first deputy director for policy and programs.

Informing the strategic refresh are lessons CMMI says were learned during its first 10 years of operation. This includes identification of a need to streamline the model portfolio and reduce complexity, and the development of tools to assist providers as they assume more financial risk in emerging payment models.

Among the five objectives of the refresh is to increase the number of beneficiaries in relationships with accountable care entities. Also established by the ACA, these entities are groups of health care providers who coordinate the care they provide for Medicare patients with the goals of improving quality and minimizing costs. Hospices are eligible to participate in ACOs through the Medicare Shared Savings Program (MSSP).

These entities could include physician group practices, Medicare Advantage plans, accountable care organizations (ACO), or PACE programs, among many others. In 2020, 67% of Medicare beneficiaries enrolled in Part A and Part B were in MA plans or were attributed to an ACO, according to CMMI.

“The arguments have been that if one entity is responsible for the care, then you’re going to get better outcomes. While intellectually that makes a lot of sense, in practice it doesn’t always work,” Banach said. “The devil is going to be in the details in terms of how they’re held accountable and what they’re held accountable for. Do we want to hold providers and payers more accountable for providing greater access to services and more equitable care? If so, then we should actually structure the benefits that way.”

The work being done at CMMI has a direct impact on hospice providers. In fact, it could reshape the industry. CMS is gradually migrating some hospice payment structures towards value-based care programs. The highest profile example to date is the hospice component of the value-based insurance design model, which tests the inclusion of those services in Medicare Advantage. 

Launched Jan. 1, the number of participants in the program will double in size during its second year, according to CMS. The program is often referred to as the Medicare Advantage hospice carve-in.

CMMI is also behind the Medicare Care Choices Model, which the agency launched in 2016. This demonstration, set to end at the end of this year, explored the idea of allowing hospice patients to receive concurrent care.

The model allows participating hospices to provide services that are currently available under the Medicare hospice benefit, but cannot be separately billed under Medicare Parts A, B, and D, while enrollees are also pursuing curative treatments.

Some in the hospice space, including the NHPCO’s Banach, have said that this model could form the chassis of a community-based palliative care benefit within Medicare.

CMMI is working to streamline its models around a cohesive strategy that drives model development and evolution. CMMI indicated in a document outlining its new strategy that the complexity of payment policies and overlap between payment models can sometimes result in conflicting or opposing incentives for health care providers.

These tendencies can dissuade some providers from participating due to the amount of necessary investment, complexity or models or participation parameters, administrative burden or lack of clarity on the long-term strategy.

The center intends to make the models and associated rules more transparent and easy to understand, and allow for simpler ways to scale and integrate them into broader CMS operations.

“There’s a need to significantly depoliticize demonstration projects. I think narrowing the focus of CMMI is going to be super helpful,” Jain told Hospice News. “The tremendous human capital that exists at the agency can then be deployed to partnering with operators in the delivery system by making sure things are set up to face the hard questions — what’s most politically and personally feasible for most patients is the focus on ensuring that their wishes are respected.”