Earlier this month, new leaders at the Centers for Medicare and Medicaid Services (CMS) published a blog post in Health Affairs about their strategic vision for the Center for Medicare and Medicaid Innovation (“CMMI” or “the Innovation Center”), a CMS subagency created by the Affordable Care Act. The mission of CMMI is to “test innovative payment and service delivery models” within Medicare and Medicaid “while preserving or enhancing the quality of care.” The post announced that CMMI’s vision for the next decade is to make equity the centerpiece of every new innovative payment/delivery model (frequently referred to as a “value-based” payment model – a model that pays health care providers based on the quality of care they provide, rather than the quantity). Community Catalyst’s Center for Consumer Engagement in Health Innovation is excited to see this new strategic direction for CMMI, and we also would like to offer three recommendations for ways CMMI can build on this commitment to further advance health equity and justice.
- Meaningfully Engage with Patients – Part of CMMI’s new strategic vision involves “considering whether and how current models meet the needs of underserved populations.” We’re particularly excited that CMMI intends to solicit more balanced stakeholder input into its model development process, especially from patient and community stakeholders. Indeed, the best way that CMMI can understand the needs of the populations it serves is through strong, ongoing meaningful community engagement. Engagement that specifically advances health equity and justice involves listening to those individuals CMMI serves who directly bear the burdens of social risk factors such as poverty, racism and cultural insensitivity, and working alongside them to identify solutions. We recommend that community engagement take place not only when CMMI is considering designing a new model, but also at the provider and/or health plan level within all future models.
- Measure Equity – CMMI also stated the importance of measuring outcomes that matter to patients, like patient-reported outcomes. We also recommend that CMMI lead the way in developing and incorporating health equity measures into its models, so that providers can be evaluated for whether and how they’re providing equitable care. Currently, many models don’t explicitly name advancing equity as a performance measure, but accounting for structural injustice and how health care providers are working to eliminate their manifestation in health care is a critical path toward achieving this goal. An innovative payment/delivery model can’t truly promote “value” or be high-quality care if it doesn’t also actively promote equity.
- Pay for Equity – Lastly, CMMI expressed interest in increasing the participation of Medicaid and safety-net providers, as well as other providers who serve low-income, racially diverse and/or rural communities, in value-based payment. One way to accomplish this goal would be to incorporate equity into the payment methodologies of these models. Payments to providers who serve individuals who have been disproportionately impacted by racism, poverty and other forms of inequity should better reflect the impact these factors have on health and well-being. A payment methodology that accurately accounts for inequity and its impact on health has the potential to aid providers in meeting the needs of these populations. However, most models currently don’t account for social risk factors and injustices in their payment methodologies. And unfortunately, some payment methodologies even unintentionally and unfairly penalize these providers, which can in turn exacerbate health disparities and inequities. CMMI should therefore consider incorporating equity into its payment models so that providers are supported and rewarded when they’re providing care that helps undo the results of longstanding systemic racism and oppression.
The next few years represent an important opportunity for CMMI – a time when it can apply the valuable lessons learned from its payment models to date as it develops new models and new partnerships for advancing health. For value-based health care to truly advance health equity and justice, it must both account for, and actively seek to dismantle, the structures and systems that perpetuate inequity. By centering, measuring and paying for equity, CMMI will be on its way to truly transforming the health care system into one that, to use its own words, “attains the highest level of health for all.”