February 23, 2023
Dr. Fowler is committed to the goal of reducing healthcare spending on a net basis into the future.
This episode was made possible by our partnership with Edwards Lifesciences.
Gary Bisbee, Ph.D.: Good afternoon, Liz, and welcome.
Elizabeth Fowler, Ph.D., J.D.: Thanks so much, Gary. Nice to be.
Dr. Gary Bisbee: Why don’t we move right into the CMS Innovation Center and your impressive leadership. Of course. For those of us that may not be totally up to speed. Would you describe the CMS Innovation Center for us please, Liz?
Dr. Elizabeth Fowler: Sure, of course. The Innovation Center was part of the Affordable Care Act that passed in 2010, and it was designed as a novel approach for testing new. Healthcare payment and delivery system models in Medicare, and then to a lesser extent Medicaid. Don Burwick our former CMS administrator and one of the nation’s foremost experts on delivery system reform described the innovation center as representing to the US Health system, what NIH is to biomedical research. . And it really was, when we were debating the ACA, there were a limited number of ideas and policies for improving quality and lowering cost. And those of us working on the legislation thought maybe the private sector was testing ideas that Medicare should consider. So we have authority to waive Medicare regulations that get in the way of coordinating care or delivering care more efficiently. And I’ll just give a couple of examples in the context of an innovation center model, we had the ability to allow greater use of telehealth before the pandemic or waive the home bound requirements for delivering more care to patients at home. Or eliminate the three day prior stay for nursing home care, we have the ability to permit flexibility to address social determinants of health for example, nutrition, transportation, et cetera. So in other words, what are the barriers, the rules, the regulations that are standing the way of care being more delivered more efficiently or effectively. And can we design a payment model or a care delivery system that eliminates those barriers?
Dr. Gary Bisbee: Thinking back to the early days, of course, you’re the Chief Health Council of Senate Finance Committee and uh, work with Senator Max Baucus. You really envisioned this center and got that into the legislation work with our good friend Nancy Ann Deparle on that. Looking back on it did you ever think you’d be the director of the center one day?
Dr. Elizabeth Fowler: No, I didn’t. I didn’t envision that actually. But I tell you, it’s a fun job and I’ve really enjoyed it. Just that ability to impact healthcare policy and hopefully make things better for patients and for the system.
Dr. Gary Bisbee: This is I suppose a tricky question, but looking back on it, now that you’ve been the director were there any changes that you wish. You had made back then, of course, without the foresight of of seeing the center and operation.
Dr. Elizabeth Fowler: I’ll maybe talk a little bit about the statutory language for success. So the statute defined success in terms of certification. So we wanna improve quality or lower cost. Hopefully we do both. But a model is certified when it has a likelihood of reducing healthcare spending on a net basis into the future. And if a model is certified, then it can be expanded in duration and scope through rulemaking. And I think maybe what we didn’t realize is the way that it was drafted and the way it’s been interpreted, that word certification really is a very high bar for success, and I think it doesn’t necessarily, the way that we’re defining success and have for the last 10 years belies the impact that we’ve had on health system transformation. So we’re now trying to step back and think more broadly about the impact we’re having on the health system. And, are we addressing health disparities? Are we changing the patient experience with their care? And maybe thinking about success a little bit more broadly. We’ll of course stay true to the statute because that’s what it says we’re supposed to be focused on, but really trying to redefine success and the outcomes for the model.
Dr. Gary Bisbee: What do you think about movement toward a value-based model, Liz? Is this something that 10 years from now, do you think we’ll be much further down the pike, or what do you think about the timing of that?
Dr. Elizabeth Fowler: Yeah I have definitely come to the conclusion that changing our healthcare system is a marathon, not a sprint for sure. , I will say, for the first 10 years of the innovation center, we planted a lot of seeds. It was this fostered a lot of innovation and innovative approaches in a lot of different areas. And took a lot of lessons from those models, but it really was a let a thousand flowers bloom approach. And I think for the second decade we really need to focus in on targeted areas that we think have a higher likelihood of this notion of health system transformation and that really has informed the strategy that we laid out in 2021. We’ve really set that bold goal of having a hundred percent of Medicare beneficiaries in an accountable care relationship with a provider who’s responsible for total cost of care and quality. And staying optimistic, I think it requires diligence, focus, and perseverance, but it also requires patients.
Dr. Gary Bisbee: You made the point, you conducted a strategic refresh in the fall of 2021 and a one year update just recently published that in November of 2022. Can you share just a high level view of those two documents and what you were trying to accomplish with each of them?
Dr. Elizabeth Fowler: Sure. I think, part of this goes up, I think it’s the role and the responsibility of the Innovation Center to really send a strong signal and a very consistent message about where we’re heading. So that, the health system knows and can predict and make the necessary investments to know where we’re heading. That was part of the reason for the strategy we put out in 2021 that really focused, like I said, on Accountable Care as the first strategic objective, the second strategic objective being around health equity. The third round supporting innovation. What are the tools and resources needed to really support that innovation. Addressing affordability, not just for the whole system and programs, but also for patients and their out-of-pocket costs. And then finally thinking about partnering to achieve system transformation and thinking more deliberately about multi-payer alignment. So that was what we laid. 2021, and then in the fall and 2022, we published a one year update. And thanks for asking about that. I think what we tried to do was really lay out how much we’d accomplished over the last year. Laid out some highlights. For example, in Accountable Care, the ACO Reach model. We saw the ACO investment model incorporated into the Medicare Shared Savings Program. We announced a new oncology model advancing health equity some of the innovative payment approaches that we’ve been testing and the requirement for a health equity plan for all our participants. . So we laid out our accomplishments and then really tried to think more about the metrics for success. So specifically in each of the five strategy areas, how are we gonna s determine whether we’re making progress? And then if you’re really into metrics, you can look at the technical paper we put out on, the baseline and how we’re measuring interim progress and our 2030 goals. So that, The point of the one year update. And to be honest, I was really taken aback by how much progress we had made and, the foundation and the building blocks. I think setting us up well for 2023.
Dr. Gary Bisbee: What kind of reaction did you receive from the field?
Dr. Elizabeth Fowler: I think there’s it’s been pretty positive, I would say. I think folks have really appreciated the way we’re trying to be more transparent in, in what we’re doing and doing a better job of communicating and sharing data and information.
Dr. Gary Bisbee: Why is it so difficult to both create and implement models of accountable care?
Dr. Elizabeth Fowler: Yeah, it’s a good question. And I think we’ve gotta think carefully about we’ve got the Medicare Shared Savings Program, which is a permanent feature of Medicare. It’s run by the Center for Medicare, so not by the Innovation Center. . I think what we’re trying to do is really coordinate a lot more closely with our colleagues across CMS to make sure that what we’re testing is relevant to the sort of overall program, the Medicare Shared Savings Program. We’ve laid out a vision together with our colleagues in other parts of the agency. And for those who don’t follow CMS, you might not know, but we’re siloed just like everyone else. And, but we’ve really tried to break down some of those silos and make sure that what we’re doing is relevant for them and that we understand where they wanna go next. So we’ve. Laid out a vision. We call it the ACO Visioning team. And we’ve also been working really closely with the Healthcare Payment Learning and Action Network, or the land. And we’ve it’s our main avenue for communicating and staying in touch with stakeholders across the system, payers, providers, health systems, purchasers and patient organizations. Spent a lot of time over the last year really defining what accountable care means. And then if you look on their website, the land website has an accountable care commitment curve, sort of everything from learning system all the way up to an aligned system and a transform system. And what are the tools and capabilities and outcomes that we’re really looking for at each stage of that of that continuum. So I think. Laying this groundwork to try to more clearly define what we mean by a accountable care. And it’s not just, we know it when we see it, but there are actual tying it to actual steps along the
Dr. Gary Bisbee: That’s just terrific. Let me shift a bit. The pandemic has obviously been distracting for everybody. In he. And one thing it seemed to do is it really stopped the interest on the providers. And I think some of the insurers in models of, I’ll just call ’em value-based models. Now we’re still grappling with the pandemic, but we’ve been through it now for a while. Do you see this willingness to innovate coming back at.
Dr. Elizabeth Fowler: Yeah, it’s a really good question, and we’re still learning how Covid has impacted this movement of value-based care. I think what we do know is that providers and health systems that had invested in value-based care were. More resilient during the pandemic. And we had hoped that we might be able to use this sense and momentum to bring others into the fold. But, I think we have to be realistic and we know that a lot of organizations are still facing ongoing challenges for providers and administrators who’ve been hesitant to adopt value-based care. We’re very attuned to these. We appreciate the workforce challenges that really permeate our health system. And it has been driving a need for more certainty, more predictability, and maybe makes providers a little bit more risk averse and nervous about jumping into a model. So it’s our job to learn how we can meet organizations where they are and help bring them along and bring them into value-based care. I think Gary, if you as we roll out new models this year, I hope you’ll see we’ve spent a lot of time thinking about how to bring these new providers into alternative payment models, and we welcome continuous feedback and input on what more we could be doing.
Dr. Gary Bisbee: Bundled payments, which. Center has a lot of experience with it, and I think when that was first proposed, there was a lot of enthusiasm on the part of providers and insurers. The reality of it probably has got in the way of that enthusiasm, if you will. But where do we stand? In the field’s view of bundle payments, just given how you given the models that, that the innovation center is is implementing.
Dr. Elizabeth Fowler: Another really important question. So in tandem with this, the release of the one year report, we released a blog on the CMS website that outlines our. Our specialty care strategy and the blog talks about our strategy to testing models and and really improve access to high value specialty care. As part of that strategy, we explained that episode-based models like the bundle payments and CJ r the comprehensive joint replacement model play an important role in maintaining. In value-based care among hospitals and health systems. So we have announced a two year extension of BPCIA advanced. And this includes a new application opportunity, which will open in the coming weeks, and we see that as really a down payment on a more comprehensive specialty care strategy. You asked about receptivity to the models in the field, and we know that all models experience attrition, particularly voluntary models and that’s been the case with Vici throughout the course of the model. And we also appreciate that hospitals and health systems have been frustrated by the res retroactive adjustments or retrospective adjustments that were incorporated into the model before I got. But they’ve made funding and revenue streams more unpredictable. So we appreciate that perspective. We’ve announced changes to the program based on feedback, and we’re looking at policies those policies and the impact on participation because it’ll be important not just to the extension of the model, but also for future episode models that we hope to roll out soon.
Dr. Gary Bisbee: Yeah. That’s good to hear. It seems to me that the focus on specialty care has increased in the last couple of years. Is that true or is it just I wasn’t focused on that before.
Dr. Elizabeth Fowler: As we were drafting the specialty strategy, we looked back and you will see over the past decades, Medicare beneficiaries have been. Faced with greater clinical and system complexity and the number of specialists that a patient may see in a year has increased substantially. And that really means increasing demands on primary care to try to coordinate all of this care. But also for patients, it’s been a challenge to navigate specialist care. So we’re, we took all of that in mind in laying out the strategy. That we put out last fall.
Dr. Gary Bisbee: Are you at the point yet where you’ve detailed the financial structure or the financial incentives that would coordinate primary care with specialty care?
Dr. Elizabeth Fowler: I think not in great detail. What we did was, and it was a blog so you know, somewhat limited in detail, but we laid out four key areas that we’re going to be looking at into the future. And I’ll just go through those really quickly. And these are part of the specialty strategy. The first is enhancing transparency of specialist data and performance measures to increase access to high quality, accountable specialty care and integration with primary care. So a data component. The second is, as I mentioned, maintaining that momentum established by the episode payment models by continuing to deploy acute tier episode based payment models. That, and, but we are thinking about how they align with ACOs and primary. . Third is supporting specialists to embed in primary care focus models. So in the short term, this means exploring the use of eConsults enhanced referrals in advanced primary care models to improve access to specialty care and reduce waiting times. But in the longer term, it means establishing financial targets for high volume, high cost specialty care within population-based. And then fourth, which is really a longer term strategy, is creating a targeted set of financial incentives for ACOs to actively manage specialty care, for example, through episode cost and quality measures that are specific to specialist managed conditions. So the, we’ve laid it out in broad strokes and I think what we plan to do this year is fill in more detail. We’re contemplating. A request for information, what are those areas where we should be delving more deeply? And we anticipate getting a lot of input from ACOs and the Medicare Shared Savings Program, as well as from the general population and those who’ve engaged with us and those who are considering it.
Dr. Gary Bisbee: The term continuum of care. Encompasses a lot of the initiatives that, that you’ve been talking about, or the patient journey, I guess would be another term that could apply here. How do you think about continuum of care, Liz, and I’m thinking particularly about the data that would allow measurement and payment for continuum of care. How do you think about.
Dr. Elizabeth Fowler: In my head, I have a picture of the patient journey. A patient who’s generally healthy and should be receiving appropriate screening and preventive services to along that continuum of patient with symptoms and a new diagnosis. That may develop into a chronic condition or a more serious health event or episode of care. And then towards the other end of the spectrum, palliative care for patients with a terminal diagnosis. We laid out this picture in the Specialty Care blog if you wanna see what’s actually in my head. And as we looked at the innovation center models, we’ve tested and invested in models across this continuum from education and Nutrition for pre-diabetics to models addressing social. To these episode models that we just discussed for discrete conditions and procedures to palliative care models. And now we’re really thinking about that integration and thinking more deliberately. I think we’re not gonna put out models just, along each part of the spectrum, but really thinking about how they work together.
Dr. Gary Bisbee: Back to the specialist primary care discussion and it would just strike me that primary care physicians. Or professionals or primary care would be more, more interested in value-based models than specialists. Have you found that or to be true or are you thinking about ways to address that?
Dr. Elizabeth Fowler: Yeah, I. I think that’s definitely true. There’ve probably been more models around sp primary care. And that’s certainly where we’re putting a lot of eggs in that sort of advanced primary care, accountable care bucket, if you will. And, it’s not to say everyone’s jumped in but we are thinking about how to bring on, as I mentioned, some of the providers who. Dip their toe into this pond yet. And what are the incentives that might bring them in? What are the tools or resources? This gets back to data. A lot of times when you asked about data, I’ve been spending a lot of time doing site visits across the country with accountable care organizations, meeting with providers and patients and this the ACOs and the need for data to be able to be successful in these models. And there’s. . There are a lot of organizations out there who provide this information and data that’s, actionable and helps helps these organizations be successful. But what are, what about the ones without the capital to invest in these data and how can we make sure that they’ve got what they need to be successful? So we need to bring on those those providers and see if we can bring them into the fold in a. Sort of, not gonna break the bank and really results in dividends, pays dividends for them. And so we’re thinking about that question. It has been easier to get providers the. Primary care level into models. But we also don’t wanna ignore specialty care because that is where a lot of the spending takes place. It’s where a lot of, the Medicare population spends a lot of time. And so we are thinking about how to bring specialists into into models over the long run, but. . But keep in mind, our fee for service system is pretty, it works pretty well for specialists. And I think the other thing we don’t wanna do is create a different model or a different payment system for every specialty group, because then we’re just perpetuating the sort of fragmentation that exists today. So it’s really about that integration and thinking about that integration.
Dr. Gary Bisbee: This is Ben as we expected. A just another outstanding interview, Liz. We’re all pulling for you. You’re doing a great job, so keep up the good work and thank you for being with us today.
Dr. Elizabeth Fowler: Thanks Gary, and thanks to all your listeners and please reach out if you have ideas for us or feedback. We welcome it.
Dr. Gary Bisbee: Super.
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