The Affordable Care Act created the Center for Medicare & Medicaid Innovation (CMS Innovation Center) within the Centers for Medicare & Medicaid Services (CMS) to “test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under” Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Since its inception, we have launched more than 50 such innovative models—targeting specific health conditions, care episodes, provider types, and communities. From 2018 to 2020, an estimated 528,000 providers, serving more than 28 million Medicare, Medicaid, and CHIP beneficiaries, participated in these models.
In 2021, after the CMS Innovation Center’s first ten years in existence, we conducted an in-depth performance review, and equity was one area of focus. Health equity is defined by CMS as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.”
One of many lessons learned from our review was that health equity was not always a priority in model design, participant recruitment and selection, implementation, or evaluation. As a result, some models have not included numbers of underserved beneficiaries proportional to their presence in the general Medicare population. Further, limited and incomplete sociodemographic data has stymied robust monitoring and evaluation of model outcomes for all populations.
This lesson is not merely an academic concern: Equity is a critical component of health care quality. For example, the Institute of Medicine’s 2001 report Crossing the Quality Chasm included as one of its six aims for health care systems providing equitable care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.
To specifically address the CMS Innovation Center’s statutory charge to test ways to enhance health care quality, we have included ‘Advancing Health Equity’ as one of our five strategic objectives for realizing the CMS Innovation Center’s 2030 vision: “A health system that achieves equitable outcomes through high quality, affordable, person-centered care.” To this end, equity will be embedded throughout our models and initiatives in four key ways:
Develop New Models And Modify Existing Models To Promote And Incentivize Equitable Care
For new models under development, we will seek to include design features that may help to address inequities in access, care quality, and outcomes. Potential options include focusing recruitment on underserved populations, quality metrics, enhanced benefits, and payment incentives or adjustments. As a first step, we are revising our model concept review processes to assess formally how new models will incorporate health equity with a lifecycle approach, from conceptualization to implementation and evaluation.
Given the length of time before new models can be developed and launched, we will also examine our portfolio of current models with at least three years of testing remaining to determine whether such models could be modified to better address equity.
Increase Participation Of Safety Net Providers
To ensure models are reaching historically underserved and under-resourced communities, we will engage safety net providers with strong community relationships, such as federally qualified health centers, community behavioral health clinics and rural health clinics, in model development. Additionally, we will examine model application and participant selection processes to identify and address barriers to inclusion of such providers and the patients we serve. Incentives to encourage and sustain safety-net provider participation may be needed, such as prospective payments, enhanced risk adjustment, and benchmark modifications, as well as technical assistance and support from model learning systems.
This work is already underway. For example, we have examined provider participation and beneficiary involvement in the Comprehensive Primary Care Plus (CPC+) and Primary Care First (PCF) models. Specifically, US census tracts were segmented according to their sociodemographic characteristics to identify segments of the population with disproportionately fewer primary care model sites. As demonstrated in exhibit 1, internal analysis suggests there are relatively fewer model participants in underserved areas, including low-income, Hispanic, and rural communities, which may indicate that these communities are less likely to be served by the models. Reasons may include lack of providers participating in the model in these areas, low numbers of underserved beneficiaries in areas where model participants are concentrated, and financial disincentives to serving underserved populations, among others. We are actively seeking to understand which of these factors, or combination of factors, are contributing to this imbalance and how the imbalance can be remedied.
Exhibit 1. Comprehensive Primary Care Plus/Primary Care First model participants located in areas with fewer low-income, rural, and Hispanic beneficiaries.
Sources: Share of Medicare beneficiaries was calculated using the average number of Medicare beneficiaries between 2015 and 2019 retrieved from the US Census Public Use Microdata files. CMMI representation was calculated by taking the number of CMMI participants present within each cluster’s census tracts divided by the total number of participants. Notes: The red coloring are qualitative representations of a cluster’s health outcomes and apparent underrepresentation by CPC+ and PCF models.
Increase Collection And Analysis Of Equity Data
The CMS Innovation Center is now supporting short- and long-term actions to facilitate such data collection. In the short term, we are working with other CMS components, as well as other agencies and offices within the U.S. Department of Health and Human Services (HHS), to identify and assess currently available data sources. We will overlay such data with existing beneficiary-level or site-specific information for purposes of monitoring and evaluating models. Further, where possible and necessary, we will rely on imputation of data, proxies for social risk (such as dual eligibility), and widely used indices such as the area deprivation index.
In the longer term, we will require model participants to collect self-reported demographic and social-needs data from beneficiaries through development of Fast Healthcare Interoperability Resources (FHIR)-based questionnaires, application program interfaces, and mechanisms for bulk data submission. This effort will be aligned with CMS’s broader equity data collection activities, which are coordinated by the CMS Office of Minority Health and based on the standards and certified health information technology (IT) requirements of the Office of the National Coordinator for Health IT.
Monitor And Evaluate Models For Health Equity Impact
In our first ten years, we did not systematically monitor or evaluate the impact of models on health equity, but we will do so moving forward to determine whether models improve health care quality for all beneficiaries, including those in underserved communities.
We have reviewed existing evaluation contracts to identify those that could be modified to require equity analyses, such as stratified quality reports, and we will conduct our own analyses of available equity data for some models, when valid data exists. For new models, evaluation contracts will include explicit requirements for equity assessments, including evidence-based, hypothesis-driven evaluation specifications, measures developed early during the model design process, and qualitative investigations of beneficiary experience.
ACO REACH Exemplifies Operationalization Of New Health Equity Strategy
The recent release of the ACO Realizing Equity, Access, and Community Health (REACH) model highlights our commitment to embed equity in new models. ACO REACH includes five provisions that we believe will help to advance equity: First, applications for this model will be reviewed and scored in part based on their experience caring for underserved populations. Second, the model requires all applicants to submit health equity plans to describe the populations they serve, the disparities that may exist, and proposed actions to address them. Third, all participating ACOs will be required to collect demographic data, which will help with model monitoring and evaluation.
Fourth, participating ACOs serving a disproportionate number of underserved beneficiaries will receive a benchmark adjustment, which will provide additional financial resources to support their care. And fifth, to increase access to care, the ACO REACH model includes an optional nurse practitioner services benefit enhancement. We anticipate these updates, which will take effect in 2023, will meaningfully improve care and reduce disparities among individuals with the greatest needs and least resources.
Achieving The CMS Innovation Center’s 2030 Vision Will Require New Collaborations
To be successful, we will leverage the knowledge, resources and authorities across CMS, as well as that of other agencies and offices within HHS. We also intend to reach beyond the walls of HHS for information and to learn from other federal departments, particularly those that are focused on provision of social services relating to food, housing and transportation; we also intend to reach out to states and external groups with deep expertise and experience in providing equitable care for underserved populations. Beneficiaries, community-based organizations and patient advocacy groups, many of whom have not historically engaged with the CMS Innovation Center, will be prioritized for outreach.
Importantly, we have begun to host a series of health equity-focused roundtable events and interviews for the purposes of soliciting new ideas and learning more about challenges to participation, which can help to inform our work. In addition, we will pursue collaborations that enable the scaling and sustaining of models that are successful in promoting equity and reducing disparities in care and outcomes. The recently announced State Transformation Collaboratives by the Healthcare Payment Learning & Action Network, which is guided by its Health Equity Advisory Team, provides one such opportunity.
A critical, strategic objective of the CMS Innovation Center is to advance health equity through model development, increased safety net provider participation, enhanced sociodemographic data collection, and robust monitoring and evaluation. Collaborations across each of these areas will be critical to inform the Center’s work and ensure accountability.
CMS Administrator Chiquita Brooks-LaSure has stated, “Our agenda is ambitious – but the times call for bold action.” The CMS Innovation Center is committed to the bold actions required to fundamentally transform our nation’s health system and ensure equitable access, quality and outcomes for all individuals served through our models and initiatives.