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CENTER FOR MEDICARE & MEDICAID INNOVATION PRIORITY ACTIONS AND IMPLEMENTATION CONSIDERATIONS

This section of the Special Publication presents a series of primary considerations for the Center for Medicare & Medicaid Innovation (CMMI). The considerations are intended to underscore the key operational changes attendees at the convenings on multi-payer alignment on value-based care and collecting data to ensure equity in payment policy that would enhance the impact and effectiveness of CMMI.

The section first lists an array of priority actions to advance progress in multi-payer alignment on value-based care and collecting data to ensure equity in payment policy. Through the six priority actions, attendees highlighted actionable priorities for CMMI to consider as key component processes to catalyze immediate action. These elements include:

1. signaling,
2. mapping,
3. measuring,
4. modeling,
5. partnering, and
6. demonstrating.

Then, the section raises several cross-cutting implementation considerations derived from the suggestions of attendees. These considerations could increase CMMI’s effectiveness and impact while achieving more commitment from a complex, multi-stakeholder landscape with various interests and needs. Namely, they urged CMMI to consider the importance of:

1. Meaningful and continuous engagement,
2. Intersectionality and diversity, and
3. Expanding CMMI activities and impact.

PRIORITY ACTIONS

1. Signaling. Reinforce and redouble sector signaling around efforts on the transition from volume to value-based care and operationalizing health data collection to catalyze alignment among field stakeholders and investments in CMMI priorities.

1. • Multi-Payer Alignment on Value-Based Care. Reinforce sector signaling and priorities on multi-payer and value-based care developments based on the groundwork laid by CMMI and the Centers for Medicare & Medicaid Services (CMS) public engagements, statements, and documents. With a defined cadence and partnerships with stakeholder organizations, help engage the stakeholder community by communicating the importance of resolving priority stakeholder concerns, providing updates on CMMI developments and progress, and announcing model specifics such as risk adjustment, benchmarks, and targets (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Reemphasize the key actions and steps that CMMI will take and asked of payers, providers, and purchasers to prioritize equity, as well as indicate the short-, intermediate-, and long-term targets for collecting, sharing, and using equity data, including collecting reliable data that can be disaggregated, categorized, and targeted by sub-populations and communities (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity and Strategic Objective 5 – Partner to Achieve System Transformation).
2. Mapping. Co-develop comprehensive roadmaps with stakeholder engagement and input to provide clear and actionable guidance, targets, and metrics, to encourage further synergistic action on value-based care and health equity data collection.
   • Multi-Payer Alignment on Value-Based Care. Set a time-line with milestones that tracks market-level progress with transparent reporting on shared metrics. To accomplish these goals, develop an actionable roadmap that includes guidance for collecting, analyzing, and applying data on core health metrics. The roadmap could benchmark the impact of efforts to align the economic incentives of providers with population health and risk-based payments. The roadmap could also outline plans for CMMI

2. • to work with select providers to move toward a position of at least 60-80% risk-based payments as a portion of their total book of business over five years as a strategy to flip providers from a fee-for-service payment structure toward population health payment models (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Develop, identify, and communicate the approaches, activities, and timelines used to meet targets through a comprehensive and actionable roadmap (e.g., providing culturally appropriate guidance through training to empower health and health care stakeholders to clarify perceived and real barriers as well as motivate widespread data collection). The roadmap would ensure field alignment by communicating guidance, best practices, incentives, requirements, and core measures (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
3. Measuring. Facilitate continuous and meaningful engagement to co-develop and validate health measures, collect, harmonize, and share health data, and disseminate peer-to-peer learning of best practices.
   • Multi-Payer Alignment on Value-Based Care. Leverage CMS’s Meaningful Measures initiative to simplify measurements to focus on the most important performance elements and use core measures with beneficiary, payer, and caregiver groups to support and track the alignment required to enable integrated person-centered care with enhanced value, outcomes, and affordability for the beneficiary (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Co-

3. • develop core data sets that measure performance on equity dimensions and display significance to field stakeholders, as well as patients, families, advocates, and communities. These measures, which should be both universal and targeted, could comprehensively account for, assess, and evaluate underserved populations’ health, care, and outcomes. The measures should include considerations across race and ethnicity, income, language, sexual orientation and gender identity, geographic and environmental context, disability status, behavioral and mental health issues, immigration and refugee status, and social drivers of health such as education, food access, health care access, and housing (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
4. Modeling. Convene field stakeholders to co-develop future alternative payment models, policies, and actions and provide sufficient technical assistance and incentives to coordinate the collection of health data and promising practices.
   • Multi-Payer Alignment on Value-Based Care. Assess the landscape of current efforts, including stakeholder mix, objectives, level and degree of progress, and alignment with CMMI goals. Then, CMMI could convene private payers to determine and resolve concerns build trust, and secure commitments from decision-makers to work on transitioning toward value-based alternative payment models (APMs). Utilizing this multi-stakeholder approach, CMMI could then work with these partners to co-develop models that establish a compelling counterfactual case against remaining within a fee-for-service payment system chassis (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Strategic Objective 4 – Improve Access by Addressing Affordability, and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Provide more substantial incentives to drive multi-stake-

4. • holder collaboration to collect equity data while providing learning tools, technical assistance, mechanisms, and funding for states, providers, and communities. States could use these resources to develop, coordinate, and lead innovations while proactively and continuously coordinating community stakeholders to inform these efforts. The resources could also help providers build and maintain the necessary capacity to collect data. Over time, the assistance would provide the collected data, documented community-based best practices and experiences, and align state, provider, and community stakeholders to test, implement, and craft community-level approaches and policies. These actions could address the needs of people disproportionately affected by institutional racism, multidimensional disparities through factors such as, but not limited, to income, disability status, sexual orientation, gender identity, and education, as well as the fee-for-service chassis (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
5. Partnering. Personalize assistance, collaborations, and approaches toward strengthening the system capacity required to adopt alternative payment models, collect health data, and leverage these data to inform CMMI’s ongoing efforts.
   • Multi-Payer Alignment on Value-Based Care. Support and facilitate APM adoption support the momentum of emerging and existing multi-payer efforts nationwide. CMMI could prioritize partnering with payers to enable flexibility in model implementation, eligibility, and requirements as part of a continuous and meaningful engagement effort. Additionally, this support would leverage personalized partnerships, scaling support, technical assistance, and continuous engagement and progress tracking to scale the adoption of APMs further. This engagement would also help CMMI rapidly incorporate learned payment, design, and implementation lessons. CMMI could also support communities, employers, states, groups, and systems cur-

5. • rently making advanced progress on implementing aligned multi-payer value-based care models or APMs within its statutory authority (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Strategic Objective 3 – Support Care Innovations, Strategic Objective 4 – Improve Access by Addressing Affordability, and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Develop a continuous and comprehensive multi-stakeholder community engagement approach that includes diverse and intersectional beneficiary perspectives as well as providers, payers, purchasers, and community-based organizations. These stakeholders would work to partner in collecting and sharing the needed data in an open, transparent, and timely manner. Through these collected data, stakeholders can better understand various perspectives, lived experiences, efforts, and unique needs at a more specific and granular scale. In addition to developing and refining approaches to advancing equity in payment policy, a multi-stakeholder partnership could help CMMI build broad-scale support and adopt their guidance and deliverables (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).
6. Demonstrating. Demonstrate the ability of payers, purchasers, providers, states, and communities to lead the transition toward value-based care and facilitate the efficient and comprehensive collection of health data.
   • Multi-Payer Alignment on Value-Based Care. Pilot new models, improvements, and programs rapidly to advance progress on key barriers and strengthen CMMI engagement with field stakeholders. Additionally, CMMI could work with 10 health systems, communities, or localities where advanced progress has been made on multi-payer alignment toward value-based care to accelerate progress and agree upon bi-directional efforts to address obstacles

6. • to success. Through this partnership, CMMI could also reallocate health care investments to the community needs beyond the health care system toward access to community resources and payment for social drivers of health services and supports (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Strategic Objective 3 – Support Care Innovations, Strategic Objective 4 – Improve Access by Addressing Affordability, and Strategic Objective 5 – Partner to Achieve System Transformation).
   • Collecting Data to Ensure Equity in Payment Policy. Test innovative and creative strategies that incentivize and facilitate the adoption of health data collection in multiple contexts and diverse, intersectional populations. These innovations could, through evidence-based mechanisms, provide promising practices for measurably reducing bias and care malpractice, improving care outcomes, and driving investments into the community and social drivers of health. These learnings could then be incorporated into future CMMI efforts and disseminated across stakeholders collaborating with CMMI (aligns with CMMI’s Strategic Objective 2 – Advance Health Equity, Strategic Objective 3 – Support Care Innovations, and Strategic Objective 5 – Partner to Achieve System Transformation).

IMPLEMENTATION CONSIDERATIONS

As CMMI moves toward accomplishing its Strategic Refresh, it faces the challenge and opportunity of translating the priority actions listed above into sustainable transformations and changes that enhance the nation’s health and health care landscape. To provide CMMI with some operational clarity in achieving its goals, attendees suggested several implementation considerations that could unlock CMMI’s full potential for learning, experimentation, and continuous improvement, listed below.

1. Meaningful and continuous engagement. CMMI was suggested to adopt a multi-stakeholder approach emphasizing meaningful and continuous engagement. This approach

1. could be employed in all areas, from setting priorities in a roadmap, developing payment approaches and health equity measures, and aligning toward the shared goals of increasing the adoption of APMs and centering the collection, sharing, and application of health equity data. Underscored throughout this emphasis was the potential impact of these transformations and enhancements on beneficiaries, the individuals the nation’s health system ought to serve.
2. Intersectionality and diversity. In the Collecting Data to Ensure Equity in Payment Policy discussion, attendees emphasized the importance of a nuanced understanding of intersectionality and diversity of critical factors and characteristics for consideration in collecting data to ensure equity in payment policy. Factors that were suggested for consideration in collecting health equity data include, but are not limited to race and ethnicity, income, language, sexual orientation and gender identity, geographic location and environmental context, disability status, behavioral and mental health issues, immigration and refugee status, and social drivers of health such as education, food access, health care access, and housing. Additionally, attendees raised that more targeted and specific approaches are often warranted for populations that experience one or more of the aforementioned factors and characteristics. Accounting for these intersecting and often overlapping identities can accurately capture the experiences and challenges faced by people in their daily lives and the impact on their health and well-being.
3. Expanding CMMI activities and impact. CMMI could integrate, expand, and match its offerings and tailor its approaches and mechanisms to different stakeholders and contexts by meaningfully and continuously engaging with field stakeholders in a catalytic fashion. CMMI could explore the possibility of assistance, initiatives, and programs beyond developing, piloting, and evaluating payment models. These programs could include technical assistance, learning tools, training, and convening supported or led by CMMI to promote and facilitate field connectivity and action.

Ultimately, the priority actions and implementation consider-