- The CMS agency that tests value-based payment models hopes to announce two new models in behavioral health and maternal health later this year, according to Liz Fowler, director of the Center for Medicare and Medicaid Innovation.
- Both upcoming models have “a heavy role” for the Medicaid program, Fowler said Thursday during a Health Affairs policy briefing. The behavioral health model, which is currently going through clearance, will also involve Medicare.
- The CMMI is also working on strategies to better integrate specialty care with primary care, a priority Fowler called “a hard nut to crack.”
The CMMI was founded more than a decade ago as part of the Affordable Care Act in an effort to move the needle toward paying for quality instead of quantity in healthcare. The models it promulgates can have major implications for government healthcare programs like Medicare and Medicaid — and their beneficiaries.
The CMS estimates more than 41.5 million people were impacted by or received care in innovation models from 2020 to 2022.
The two upcoming models target worsening crises in U.S. healthcare.
Behavioral health needs in America have skyrocketed, with one in five adults now receiving mental healthcare, an increase of almost 15 million people over the past two decades. An estimated 15% of adults had a substance use disorder in the past year, yet the vast majority are not receiving treatment, according to Mental Health America.
Agency leaders have hinted before they’re exploring models targeting behavioral healthcare as the Biden administration continues to focus on addressing the U.S. mental health and addiction crisis.
Meanwhile, the U.S. has some of the worst maternal health outcomes out of all developed nations, with 33 deaths per 100,000 live births in 2021. For Black women, that rate jumps to 70 deaths per 100,000 live births, according to the Centers for Disease Control and Prevention.
But the timing of the new behavioral health and maternal health models could be stymied by the ongoing funding impasse on the Hill, Fowler said. The U.S. is inching toward a government shutdown, with funding slated to run out at the end of this month.
“Some of it will depend on — dare I say it — whether the government remains open, and the Congress finds a way to keep funding the government starting in the new fiscal year,” Fowler said.
The CMMI is also continuing to develop initiatives to bring value-based payments to specialty care. The agency recently extended a bundled payments model for care episodes for another two years, and earlier this summer issued a request for information about future episodic models.
“We hope to put out a rule in our direction with that approach in the beginning of next year,” Fowler said. “Again, not just doing a model to do a model, but really thinking about how that specialty care and those episodes would integrate with accountable care and with primary care.”
CMMI is also looking at how it can provide better data to accountable care organizations and advanced primary care practices to help them manage specialty care, Fowler said.
Fowler joined the CMMI in 2021, and has overseen a strategic refresh at the agency following criticism about model efficacy and its broad authority to test payment systems without congressional approval.
Over its tenure, the CMMI has tested more than 50 models, but only four have met the criteria for expansion and gone on to permanently become part of Medicare. Twenty-five models are currently active.
The goal of the refresh is to streamline its portfolio, resulting in fewer but better models with a stronger focus on health equity and data quality.
The CMMI is aiming to get every fee-for-service Medicare beneficiary and the “vast majority” of Medicaid beneficiaries in an accountable care arrangement by 2030.