THE LEARNING HEALTH SYSTEM SERIES
Catalyzing Innovative Health System Transformation: An Opportunity Agenda for the Center for Medicare & Medicaid Innovation
NAM Leadership Consortium: Collaboration for a Learning Health System
NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by NAM signifies that it is the product of a carefully considered process and is a contribution worthy of public attention but does not constitute endorsement of conclusions and recommendations by NAM. The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; NAM; or the National Academies of Sciences, Engineering, and Medicine.
This initiative was convened with support from The Commonwealth Fund. Any opinions, findings, or conclusions expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for this project.
International Standard Book Number-13: 978-0-309-69235-9
International Standard Book Number-10: 0-309-69235-0
Digital Object Identifier: https://doi.org/10.17226/26675
Copyright 2025 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
Suggested citation: National Academy of Medicine. 2025. Catalyzing Innovative Health System Transformation: An Opportunity Agenda for the Center for Medicare & Medicaid Innovation. P. S. Chua, A. Anise, J. Lee, M. Cohen, P. Conway, J. Harris, P. Long, M. B. McClellan, D. Muhlestein, A. S. Navathe, R. Onie, E. Park, and R. Perla, editors. NAM Special Publication. Washington, DC: National Academies Press. https://doi.org/10.17226/26675.
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CATALYZING INNOVATIVE HEALTH SYSTEM TRANSFORMATION: AN OPPORTUNITY AGENDA FOR THE CENTER FOR MEDICARE & MEDICAID INNOVATION
Expert Panel and Steering Committee
MANDY COHEN, Aledade Care Solutions
PATRICK CONWAY, Care Solutions, Optum
JULIAN HARRIS, Healthcare Services, Deerfield
DORA HUGHES, The George Washington University (until July 2021)
PETER LONG, Blue Shield of California
CINDY MANN, Manatt Health (until August 2021)
MARK B. MCCLELLAN, Robert J. Margolis Center for Health Policy, Duke University
DAVID MUHLESTEIN, Leavitt Partners
AMOL S. NAVATHE, Perelman School of Medicine, University of Pennsylvania
REBECCA ONIE, The Health Initiative
EDWIN PARK, McCourt School of Public Policy, Georgetown University
ROCCO PERLA, The Health Initiative
MEENA SESHAMANI, MedStar Health (until July 2021)
NAM Staff
Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of J. Michael McGinnis, Leonard D. Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value & Science-Driven Health System:
PEAK SEN CHUA, Consultant (until July 2023)
AYODOLA ANISE, Deputy Director, NAM Leadership Consortium (until February 2023)
JENNIFER LEE, Visiting Scholar (until June 2022)
JENNA L. OGILVIE, Deputy Director of Communications (until April 2023)
ALLISON LESTER, Senior Program Assistant (until March 2022)
OLIVIA MATONGO, Program Officer (until November 2021)
ARIANA BAILEY, Senior Program Assistant (until August 2021)
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NAM LEADERSHIP CONSORTIUM: COLLABORATION FOR A LEARNING HEALTH SYSTEM
MARK B. MCCLELLAN (Chair), Duke University
AMY ABERNETHY, Verily
SHANTANU AGRAWAL, Anthem Inc.
JEFFREY BALSER, Vanderbilt University Medical Center
GEORGES BENJAMIN, American Public Health Association
RACHELE BERRIA, AstraZeneca
DAVID BLUMENTHAL, The Commonwealth Fund
NAKELA COOK, Patient-Centered Outcomes Research Institute
KAREN DESALVO, Google
JUDITH FAULKNER, Epic Systems
DAVID FEINBERG, Cerner
JULIE L. GERBERDING, Merck & Co., Inc.
SANDRA HERNANDEZ, California Health Care Foundation
DIANE HOLDER, UPMC Health Plan
MICHELE HOOD, American Hospital Association
FREDERICK ISASI, Families USA
ADAM LENKOWSKY, Bristol Myers Squibb
PETER LONG, Blue Shield of California
JAMES L. MADARA, American Medical Association
LAURA MAURI, Medtronic
SUZANNE MIYAMOTO, American Academy of Nursing
VALERIE MONTGOMERY RICE, Morehouse School of Medicine
MARY D. NAYLOR, University of Pennsylvania
HAROLD PAZ, Stony Brook University
JONATHAN B. PERLIN, The Joint Commission
RICHARD PLATT, Harvard Medical School
DWAYNE PROCTOR, Missouri Foundation for Health
KYU RHEE, CVS Health, Aetna
JOHN W. ROWE, Columbia University
LEWIS G. SANDY, UnitedHealth Group
LEONARD D. SCHAEFFER, University of Southern California
BRUCE SIEGEL, America’s Essential Hospitals
DAVID SKORTON, Association of American Medical Colleges
JENNIFER TAUBERT, Johnson & Johnson
REED V. TUCKSON, Tuckson Health
DEBRA B. WHITMAN, AARP
NAM Leadership Consortium Staff
LAURA ADAMS, Senior Counsel
AYODOLA ANISE, Deputy Director (until February 2023)
SARAH GREENE, Senior Counsel
AMANDA HUNT, Senior Program Officer
J. MICHAEL MCGINNIS, Executive Director
ANNIE MURFF, Senior Program Assistant
ASIA WILLIAMS, Research Associate
REVIEWERS
The products that compose this volume were reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine (NAM).
We wish to thank the following individuals for their contributions:
IGNATIUS BAU, Independent Consultant
CHRIS DEMARS, Oregon Health Authority
TRICIA MCGINNIS, Center for Health Care Strategies
JORGE PETIT, Coordinated Behavioral Care, Inc.
The reviewers listed above provided many constructive comments and suggestions, but they were not asked to endorse the content of the publication and did not see the final draft before it was published. Review of this publication was overseen by AYODOLA ANISE, Deputy Director, Leadership Consortium; PEAK SEN CHUA, Consultant; JENNIFER LEE, Visiting Scholar; and J. MICHAEL MCGINNIS, Leonard D. Schaeffer Executive Officer. Responsibility for the final content of this publication rests entirely with the editors and NAM.
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PREFACE
Continuous learning aligned with multi-stakeholder engagement is critical in driving the nation’s health and health care system toward improved effectiveness, efficiency, and equity. Since its founding in 2010 as a key provision of the Affordable Care Act, the Center for Medicare & Medicaid Innovation (CMMI) has tested more than 50 alternative payment models reaching more than 28 million patients across 528,000 health care providers and plans, yielding invaluable insights on the implementation of models to achieve better care, better health, and lower costs. In the ensuing decade, the field’s understanding of the necessary programs, policies, and efforts to achieve equity, affordability, and value has advanced considerably.
On the other hand, many basic lessons learned are lessons unapplied. Population health outcomes in the United States lag behind its highly economically developed peers. Our nation’s health system is still firmly entrenched in the fee-for-service payment system that rewards service volume. This system has delivered lackluster health and health care access, outcomes, efficiency, and affordability. Additionally, health care expenditures continue to rise despite multi-dimensional disparities in morbidity, mortality, and overall health and well-being. During the COVID-19 pandemic, the health system’s emphasis on volume instead of value and the society-wide impacts of structural racism were exposed to poor overall outcomes and worsened health outcomes for marginalized populations.
The opportunity, indeed the obligation, is clear for CMMI to enhance its role as a catalyst of the changes needed. Reflecting this urgency, CMMI leadership began consultations and outreach efforts in service of its updated strategic plan in early 2021. Anticipating CMMI’s need for guidance and technical advice, the
National Academy of Medicine (NAM) sought to leverage its strengths in convening field stakeholders and industry leaders to inform this updated strategic plan. With the generous support of The Commonwealth Fund, NAM launched its two-phase Catalyzing Innovative Health Transformation initiative in March 2021.
In the project’s first phase, NAM convened an Expert Panel of preeminent and innovative leaders to assess the state of health financing and care delivery. In the culminating Expert Panel Review, the panel urged CMMI to focus on targets and measures to enhance beneficiary interests, equity in payment policy, community and social drivers of health, and multi-payer alignment on value-based care. The Expert Panel was refashioned into a Steering Committee in the second phase. The Steering Committee and NAM convened interactive discussions on Multi-Payer Alignment on Value-Based Care and Collecting Data to Ensure Equity in Payment Policy. Recognizing that these two domains are crucial to reducing fee-for-service dominance, these discussions reviewed landscape of challenges faced and illuminates the strategies CMMI can pursue to achieve systems transformation.
Ultimately, these efforts informed CMMI’s Strategic Refresh, which was launched in October 2021. CMMI’s updated strategic plan cited NAM’s efforts in refocusing the center’s aim on transitioning the health system toward value-based care and achieving equitable outcomes through high quality, affordable person-centered care. The initiative also sought to inform CMMI’s efforts beyond the Strategic Refresh. Across the initiative, stakeholders and field leaders signaled to CMMI the boundless possibilities from a stakeholder engaged transformation that co-develops approaches, strategies, deliverables, and supports.
This Special Publication, Catalyzing Innovative Health System Transformation: An Opportunity Agenda for the Center for Medicare & Medicaid Innovation, is a product of this effort—a resource for CMMI as it advances its strategic agenda. It outlines the need to center beneficiaries as the north star, assure the primacy of equity as well as linkages with community and personal drivers of health, and align payers to reward whole person and population health. Moreover, the convenings emphasized the compelling, disruptive opportunities CMMI could harness by refocusing
its operative approach. Constructing systems that reward whole person and population health at scale will require more creative, engaged, and co-developed tactics, strategies, and programs.
These efforts include CMMI using its convening power to align various stakeholders within the health ecosystem, assessing the current landscape of efforts, identifying new ways to personalize and support external stakeholders, engaging stakeholders in co-developing models and data collection efforts, testing models more rapidly, and aggregating available data to supercharge current efforts.
NAM and the NAM Leadership Consortium for a Learning Health System, look forward to assisting CMMI and its stakeholders throughout the nation—from individuals, families, and communities to payers, providers, employers, and states—in advancing a health system that reaches its potential for effectiveness, efficiency, equity, and continuous learning.
J. Michael McGinnis
Leonard D. Schaeffer Executive Officer
Executive Director, NAM Leadership Consortium
National Academy of Medicine
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CONTENTS
1 Introduction and Initiative Background
2 Expert Panel Review Highlights
3 Multi-Payer Alignment on Value-Based Care Discussion Highlights
4 Collecting Data to Ensure Equity in Payment Policy Discussion Highlights
5 Center for Medicare & Medicaid Innovation Priority Actions and Implementation Considerations
B Multi-Payer Alignment on Value-Based Care Discussion Proceedings
C Collecting Data to Ensure Equity in Payment Policy Discussion Proceedings
E Meeting Participants for September 28, 2021, Meeting on Multi-Payer Alignment on Value-Based Care
F Meeting Agenda for September 28, 2021, Meeting on Multi-Payer Alignment on Value-Based Care
H Meeting Agenda for November 1, 2021, Meeting on Collecting Data to Ensure Equity in Payment Policy
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ACRONYMS AND ABBREVIATIONS
| ACA | Affordable Care Act |
| ACO | Accountable Care Organization |
| ACT | adult changes in thought |
| AHC | Accountable Health Communities |
| AHCPII | Arkansas Health Care Payment Improvement Initiative |
| APM | alternative payment model |
| CAHPS | Consumer Assessment of Healthcare Providers and Systems |
| CCSQ | Center for Clinical Standards and Quality |
| CHIP | Children’s Health Insurance Program |
| CMCS | Center for Medicaid and CHIP Services |
| CMMI | Center for Medicare & Medicaid Innovation |
| CMS | Centers for Medicare & Medicaid Services |
| COVID-19 | coronavirus disease 2019 |
| CPC | Comprehensive Primary Care |
| CPC+ | Coordinated Primary Care Plus |
| CPT | Current Procedural Terminology |
| ED | emergency department |
| EPHC | Enhanced Personal Health Care |
| ER | emergency room |
| FFS | fee-for-service |
| HCC | Hierarchical Condition Category |
| HCP-LAN | Healthcare Payment Learning and Action Network |
| HEDIS | Healthcare Effectiveness Data and Information Set |
| HESS | Health Equity Summary Score |
| HHS | U.S. Department of Health and Human Services |
| HIE | health information exchange |
| HITECH | Health Information Technology for Economic and Clinical Health Act |
| IT | information technology |
| LGBTQ+ | lesbian, gay, bisexual, transgender, and queer or questioning |
| NAM | National Academy of Medicine |
| NASHP | National Academy for State Health Policy |
| NCQA | National Committee for Quality Assurance |
| NQF | National Quality Forum |
| NQIIC | Network of Quality Improvement and Innovation Contractors |
| ONC | Office of the National Coordinator for Health Information Technology |
| PBGH | Purchaser Business Group on Health |
| PBPM | per-beneficiary per-month |
| PCF | Primary Care First |
| PCMH | Patient-Centered Medical Home |
| PCP | primary care provider |
| PFAC | Patient and Family Advisory Council |
| PMPQ | per-member per-quarter |
| SHARE | Arkansas State Health Alliance for Records Exchange |
| SOGI | sexual orientation and gender identity |
| VBC | value-based care |
| VBP | value-based payment |
