Q&A with Elizabeth Fowler of the Center for Medicare and Medicaid Innovation: ‘We want to be a good partner to good actors’

What would you say to progressives and other groups that wanted to see Medicare direct contracting thrown out or changed more drastically than you have?

I would start by saying that we did, in fact, permanently cancel the Geographic Direct Contracting Model, which has been on hold since March of last year. And there was a lot of confusion between the Geo Model and the Global and Professional Direct Contracting Model. It seems like some of the criticism about GPDC was based on some features included in the Geo Model, so I hope this step puts to rest some of that criticism.

Second, we made important changes that address concerns raised by critics. In addition to the focus on health equity and the shift toward provider-led organizations, we tightened the risk adjustment policy—and of course the increased monitoring and compliance activities.

Finally, I just want to add that an immediate end to GPDC—or any innovation model—could result in care disruption for beneficiaries. Patients served by accountable care organizations can receive care that they might not get under traditional Medicare, like greater support managing chronic conditions, supporting transitioning from the hospital to their homes, transportation assistance and in some cases, Part B cost-sharing assistance. Ending the model would also be disruptive to participants, and we want to be a good partner. We want to be a good partner to good actors, including many who have succeeded in prior CMMI models.

Some people have also raised concerns that even with such big changes to a model, CMMI might lose the trust of some participants. How do you plan to mitigate that?

We have to do a good job of communicating the changes we’re making and why we’re making them. And I’ll tell you, we’ve received a lot of positive feedback about the changes from participants. This isn’t surprising given that a lot of the changes we made were in response to the experience participants had during the first year of the program. In fact, we’ve talked to participants in other models who are now asking if we’ll consider adding the health equity policies to those models.

We value our model participants and understand the effort and resources that go into participating. Our goal is to be transparent with model participants, the general public and particularly beneficiary groups as we work together on important information that we need to improve models over time. Regarding current model participants, I think it bears saying that those who meet the requirements of the ACO REACH model who are participating today will be able to continue participating. We’re committed to value-based care. We believe the infrastructure investments made to date will continue to provide valuable benefits to Medicare beneficiaries and to the Medicare trust funds.

This all will require a lot of relationship building and trust building with participants, both current and future. Are there any specific activities in that sphere that you plan to undertake?

Regarding the monitoring and compliance activities, again, we want to ensure that beneficiaries are receiving the best care possible. So we’re committed to making sure that (direct contracting entities) this year and ACOs going forward adhere to the requirements of their participation agreements with CMS. Doing that involves monitoring compliance for both GPDC and ACO REACH. So in addition to reviewing marketing materials and communications sent to beneficiaries, and investigating beneficiary complaints, we’ll be using more data analytics to monitor use of services over time, and comparing that to a reference population. This will allow us to assess whether there have been changes in beneficiaries’ access to care. We’ll look annually at whether beneficiaries are being shifted into Medicare Advantage and looking more closely at inappropriate risk score growth. We plan to continue our audits of contracts that ACOs have with providers and learn more about their downstream arrangements, and identify any concerns. And we’ll monitor for non-compliance with prohibitions against anti-competitive behavior and misuse of beneficiary data. We have the capacity today and we are ready to carry out these new activities.

Where does the funding for these activities come from? Do you expect this to create any extra burden on model participants?

We don’t expect that it will create a burden for model participants. It will be more of a burden on CMS. I think we have the data needed to make sure we have the resources and capabilities. We can use some existing resources, and I need to make sure they’re not stretched too thin, but we think we have the capacity to do it.

You’ve mentioned health equity. ACO REACH addresses those issues head-on, and we know this is a major priority for CMMI models going forward. Tell us more about how you plan to monitor the models’ health equity impacts.

This is a really important point. As I mentioned, we’re really pleased with the direction of these new policies. You can expect future CMMI models to include features from ACO REACH, like the requirement of a health equity plan. In fact, regarding ACO REACH, this design really laid a lot of groundwork for our thinking and we engaged in partners across CMS and HHS to operationalize this model with meaningful requirements to advance health equity. We’re continuing to explore avenues on how to increase the number of beneficiaries from underserved communities, in part by increasing participation of providers that serve them. We’re looking more closely at the application and selection processes for our previous models to identify barriers and challenges that some providers might have faced in participating, and our findings will inform potential changes.

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We would be remiss not to mention the COVID-19 public health emergency. What role might CMMI play in continuing new care delivery systems made possible by waivers once the PHE is over?

We’re having those conversations right now at CMS. It comes back to the question of what is the purpose of CMMI. I believe it should be used to test ideas for ways to make the health system better. If we discovered something that worked really well during the pandemic, those good ideas should become a permanent part of the CMS programs. And if there are care-delivery flexibilities and innovations from the PHE that increased access to care, then we should consider including and testing them and further CMMI models. We intend to be doing that review and looking more closely for sure.