During a fireside chat held at this week’s Health Care Learning and Action Network summit meeting, the Center for Medicare & Medicaid Innovation’s Sarah Fogler, Ph.D., M.A., reflected on CMMI’s decade of experience with creating alternative payment models for specialty care, and also spoke about upcoming opportunities in this space.
Fogler serves as the acting director of the Patient Care Models Group, which develops and implements episode-based payment initiatives, including the Bundled Payments for Care Initiative – Advanced Model, Comprehensive Care for Joint Replacement Model, Oncology Care Model, Enhancing Oncology Model, Independence at Home Demonstration, and the Intravenous Immunoglobulin Demonstration. Prior to joining the CMS Innovation Center, she served as the senior director of population health and community benefit at Greater Baltimore Medical Center in Baltimore.
She was interviewed by Amol Navathe, M.D., Ph.D., a tenured faculty member in health policy and medicine and a senior fellow at the Leonard Davis Institute for Health Economics at the University of Pennsylvania. He is vice chairman and commissioner of the Medicare Payment Advisory Commission (MedPAC), a non-partisan agency that advises the U.S. Congress on Medicare policy.
Fogler noted that the CMS Innovation Center has established a comprehensive strategy to incorporate specialists into value-based payment programs aligned with the CMS Innovation Center Strategy Refresh.
“Over the past decade, we have built and are continuing to refine a strong foundation of accountability across a number of key specialties and conditions. We did this alongside but separately from our model tests of advanced primary care and accountable care organizations,” she said. “As the strategic refresh turns its focus toward improving specialty care, we expect these accountability structures to coordinate with or more fully integrate specialty care to deliver whole-person care for Medicare and Medicaid beneficiaries.”
To date, she explained, the specialty care models have focused on inpatient medical and surgical admissions and procedures in hospital outpatient departments. There are episode-based payment models including the bundled payments for care improvement initiative models and a comprehensive care for joint replacement model. “These models have driven transformational change in the delivery of care across transitions, namely between hospitals post-acute care and community-based supports,” she said.
Fogler added that in addition to episode-based payment models, CMMI has made gains through specialty models that focus on conditions — specifically for oncology and kidney disease, including the Oncology Care Model and the new Enhancing Oncology Care Model and Kidney Care Choices and the comprehensive ESRD model. “There are remaining opportunities around fragmentation between primary care providers and specialists, increasing access to high-quality specialty services, and getting more specialists involved in value-based payment generally. So that’s where we’re focusing key areas in our specialty strategy moving forward.”
Navathe asked Fogler to go into more detail about the primary care/specialist interface, because, he said, “many of us who work in the space, who study this space, who are trying to be innovators, struggle with this.”
“We have four explicit, discrete areas of focus in our specialty care strategy, and it’s very purposefully reaching across the entire continuum of care for beneficiaries,” Fogler replied. “The first area of focus in specialty strategy is around sharing data to enhance transparency and clinician performance. This isn’t a new area for the agency, of course, but we are putting targeted focus on doing a better job of arming our provider partners with data to make informed decisions about who they want to engage with as their specialty care partners.”
She said the second area of focus is continuing CMMI’s history of broad-based episode-based payment model tests that align purposefully with ACOs and primary care, and that would include mandatory models moving forward.
The third prong of the specialty care strategy is supporting specialists to further embed in primary care-focused models. “We haven’t explicitly tested a primary care model, although we’ve done tons of work in the primary care space, really layering in that specialty care partnership within the primary care model base that we’ve tested at the innovation center,” she said, “so we are excited to do some more work there.”
The fourth element of the specialty care strategy is creating incentives within population-based models to encourage specialty care integration. That doesn’t necessarily mean new models, Fogler said. “It could be tools and different programmatic waivers or other such elements that we could introduce into our population-based portfolio that could encourage specialty care integration.”
Navathe asked Fogler for more detail about creating incentives for specialist integration into models that are essentially designed for primary care or populations. “I might imagine this, for example, as co-located endocrinology for diabetes patients. Are these incentives for that kind of structural change in the delivery model? Or is it more around the outcomes? Trying to explore this interface between PCP and specialists?”
“I will say the fourth prong of the strategy is one that we have identified as being longer-term,” Fogler replied. Lessons learned in the shorter term will inform that fourth prong, she said, adding that they are considering a few different levers. One is around changing beneficiary alignment algorithms to move beyond just traditional E/M outpatient services and to include some more of the hospital-based services. “For example, we’re also considering developing subpopulation targets for high-volume or high-cost conditions that either can be introduced again through the formality of model design or through the informality of tools and supports arming, for example, ACOs with additional information on what their conditions are costing within their network and for their attributed beneficiaries,” she said.
Fogler noted that CMMI realizes that the math of an ACO is different for integrated delivery systems and hospital-led ACOs versus physician-led ACOs. “That’s been a distinguishing feature of that fourth prong of the specialty strategy is really thinking thoughtfully about how the levers need to look different for hospital-led versus physician-led ACOs,” she said. “One key piece of that puzzle that we’ve begun to unpack is that hospitals can’t always justify decreasing referral volume if an ACO shared savings rate doesn’t sufficiently cover the foregone revenue, so it makes sense that the ACO savings to date have been concentrated among physician-led ACOs.”
Meanwhile, she added, the most rapid vertical integration has occurred among specialty practices compared to primary care, namely in oncology and cardiology, meaning these specialty practices are increasingly owned by hospitals and less likely to affiliate with PCP ACOs. “We know we need tailored approaches and incentives for these types of different model participants with different economic and market-based incentive structures,” Fogler said. “Our plan is to work over the next few years while we’re building strategies to support the first three elements of the specialty strategy to really inform the future design of this fourth integrated population-based specialty strategy.”