CMMI seeks to boost specialty, primary care coordination

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[MM Curator Summary]: CMS (via CMMI) is trying to redirect ACO unicorns to redirect to primary care.



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The Biden administration wants primary care and specialty providers to work closer together, including via new population-based payment models to bolster referrals to specialists.

The Center for Medicare and Medicaid Innovation (CMMI) released a report Monday updating its strategic vision for implementing value-based care, including detailing its progress since the vision was released last year. One of the key new strategies focused on creating greater care coordination between primary care doctors and specialists, especially surrounding the types of models the center puts out.

“We can’t have accountable care if our episode models were providing incentives for providers to do their own thing and not integrating with primary care,” said CMMI Director Liz Fowler in an exclusive interview with Fierce Healthcare.

The center spoke with a wide array of stakeholders that found existing episode-based cost measure models at times overlapped. 

Several experts have called on CMMI to design any future episode-based payment models (which pay the provider based on the cost for an entire episode of care) to align “incentives between specialists and population-based model initiatives,” the report said.

Population health models can offer incentives that will encourage providers to focus on the prevention of chronic conditions and better management to avoid the episodes altogether, Fowler said. 

CMMI is also looking into what tools and data are needed to support a better connection between specialists and primary care doctors. 

The center, for instance, could rely on e-consults and “other tools that facilitate data exchange to increase referrals of high clinical value and to help ensure effective follow-up,” an accompanying CMMI blog post said.

CMMI is also hoping to roll out next year or in 2024 a new advanced primary care model that would ensure equitable access by recruiting safety net and Medicaid providers. 

The Centers for Medicare & Medicaid Services (CMS) has already finalized some changes intended to get more providers involved in payment models that provide care for rural and underserved populations. The agency recently finalized new upfront investments and changes to the accountable care organization benchmark to ease some of the startup costs for joining an ACO or payment model. 

Other efforts to help such providers include offering longer time frames for applications and offering greater technical support “to be able to figure out if this model can work for them,” Fowler said. 

She added that CMMI is exploring evaluating such safety net providers based on different quality metrics than other payment models, including targeted measures that apply to the provider’s population such as if they serve a large share of Medicaid patients. 

Health equity has been a major pillar for CMMI and the Biden administration. The center’s new ACO REACH model, which goes live in January, includes a requirement for participants to create a health equity plan that identifies disparities in care and a plan to address them. 

ACO REACH also incorporates a “health equity benchmark adjustment” that can boost payments to providers that serve dual-eligible Medicare-Medicaid beneficiaries amid other underserved populations.

Staying out of court

The center is also working on a report to identify model tests that can lower drug costs for Medicare and Medicaid beneficiaries. Fowler said center staff members are currently holding listening sessions with stakeholders such as manufacturers, payers and patient organizations on what it can do.

CMS has waded into prescription drug prices before, during the Trump administration, when it approved a controversial model to change the prices for certain Medicare Part B drugs to the price paid by several countries overseas. 

The controversial Most Favored Nation model was finalized at the tail end of the Trump administration but was officially pulled by the Biden administration in January of this year after a legal fight with the pharmaceutical industry. Fowler said the center hopes to not be embroiled in a similar legal fight with their next approach. 

“We want to make sure that we’re proposing models that are implementable and impactful,” she said.