Tuesday, Jul 26, 2022

The time is now to drive high-quality, whole-person care

Meena Seshamani, MD, PhDDeputy Administrator and Director of the Center for Medicare, Centers for Medicare & Medicaid Services


Driving innovation to promote high-quality, whole-person care is a central pillar to the vision for Medicare, and one that can only be accomplished in partnership with the health care ecosystem caring for the 63 million people who depend on the Medicare program to keep them healthy. A key lever in this is the Medicare Shared Savings Program (Shared Savings Program), which is the largest Accountable Care Organization program in the country serving more than 11 million people with Medicare. As we mark the 10-year anniversary of the Shared Savings Program, the Centers for Medicare & Medicare Services (CMS) has proposed changes that, if finalized, represent some of the most significant reforms to the program since its inception, driving towards our goal of having all people with Traditional Medicare in an accountable care relationship with a provider by 2030. These proposed changes open tremendous opportunities for partnership in innovation with providers, payers, and others committed to improving care – particularly in rural and underserved areas that may be as yet untouched by the changes in care delivery that hold promise for better care, smarter spending, and healthier populations.

Shared Savings Program ACOs are groups of doctors, hospitals, and other health care providers who join together voluntarily to give coordinated, high-quality care to people with Medicare with the goal that people receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO may be eligible to share in the savings it achieves for the Medicare program. In certain instances, an ACO may owe a portion of losses to the program if it increases Medicare costs. 

In the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) proposed rule, there are several policies that will encourage growth of this program, leverage its holistic approach to care to advance health equity, and create alignment with other innovative programs in order to create momentum for change on the ground. These policies include:

  • A proposal that builds on the CMS Innovation Center’s successful ACO Investment Model (AIM) to incorporate advance shared savings payments to certain Shared Savings Program ACOs that could be used to address Medicare beneficiaries’ social needs – one of the first times Traditional Medicare payments would be permitted for such use. The expectation is that this proposal, if finalized, would be an opportunity for many providers in rural and other underserved areas to join together as ACOs, build the infrastructure needed to succeed in the program, and promote equity by holistically addressing patient needs, including social needs.
  • A proposal to permit smaller ACOs more time to transition to downside risk, helping to grow participation in rural and underserved communities. This proposal is responsive to interested parties’ concerns that particularly smaller providers in rural and underserved settings need additional time to transition to two-sided risk, and that quickly forcing providers to adopt two-sided risk models was a barrier to participation in the Shared Savings Program. 
  • A proposal for a health equity adjustment to reward excellent care delivered to underserved populations. This proposal represents one of the first that would promote equity in a value-based care program, while simultaneously avoiding the pitfalls of other pay-for-equity type approaches (this health equity adjustment would not risk adjust away or mask disparities, and does not set lower quality standards for underserved populations).
  • A proposal for financial benchmark adjustments to make it so that more ACOs can participate and succeed. As we seek to increase the percentage of people with Medicare in accountable care arrangements, we are balancing incentives and participation options to serve a dual purpose of sustaining participation by existing ACOs and increasing program growth.  
  • A Request for Information to gather public feedback on an alternative approach to calculating ACO benchmarks that would use administratively-set benchmarks decoupled from fee-for-service spending. CMS has observed that the benchmarking methodology for the Shared Savings Program and Innovation Center models may include ratchet effects that reduce benchmarks for successful ACOs and jeopardizes their continued participation over multiple agreement periods, resulting in selective participation (including limited participation by inefficient ACOs).

In addition to these proposed changes to the Shared Savings Program, there are other aspects of the PFS rule that promote whole-person care. We are proposing to pay psychologists and social workers to help manage behavioral health needs as part of the primary care team, in addition to on their own, because it can be easier for a person to get behavioral health care like psychotherapy when the care is coordinated through their primary care doctor. And, we are requesting information about how Community Health Workers (CHWs) are involved in Medicare Part B services furnished by eligible practitioners and providers, in light of the benefits that services involving CHWs can potentially have on the health of people with Medicare, including a reduction in health disparities.

Through these proposals, we hope to catalyze continued movement towards better care, smarter spending, and healthier populations. As we engage Medicare beneficiaries, clinicians, and the communities we serve throughout the policymaking and implementation process, we are inviting health care providers and other innovators in care delivery to work with us to meet our 2030 goal of 100 percent of people in Traditional Medicare in an accountable care relationship, and to further drive the success of our collective programs.  

Medicare remains a bedrock of our nation’s health system and has significant influence on how it operates. Achieving our goals in Medicare will have an outsized influence on health care delivery across the country. We are committed to working with ACOs and other health care innovators to continue to strengthen Medicare, not only for the next ten years, but for generations to come.

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