CMS Focusing on Better Aligning Quality Measures, Adding New ACO Models

Are you exasperated by all the different quality measures you’re required to report? One official at the Centers for Medicare & Medicaid Services (CMS) knows exactly how you feel.

“I led care transformation at a health system before coming into this role, and we had this huge spreadsheet of the 500 different metrics from all the different payers and all the different programs,” Meena Seshamani, MD, PhD, director of the Center for Medicare at CMS, said Monday during a virtual summit on value-based care sponsored by the Heritage Provider Network. “And then you spend all of your time just trying to navigate a spreadsheet and debating whether diabetes control is HbA1c less than 8 or HbA1c less than 9, rather than talking about how we are addressing the care of our diabetics.”

That’s why CMS is now trying to align quality metrics across all of its programs, including Medicaid, the Affordable Care Act marketplace, traditional Medicare, Medicare Advantage, and models from CMS’s Center for Medicare & Medicaid Innovation (CMMI), “so that we can have a core set of metrics … and you can really focus people’s energy toward actually changing the way care is provided,” she said.

CMS wants to hear from people affected by its policies, Seshamani added. “It is great to put something in a 2,000-page regulation that goes into the Federal Register, but what matters to people is how that ultimately impacts the care that they get, or for someone who has gone into a healthcare field, what kind of care they can provide to someone. So it’s very important to us that we’re also engaged with those on the ground,” to hear what could use improvements, as well as how much a particular program has helped someone.

With regard to value-based care programs, the agency wants to hear from people on both ends, said CMMI Director Liz Fowler, JD, PhD. “We would really welcome input on the tools, strategies, and resources that would make it easier or more likely for organizations to be part of value-based care,” she said. “So on that front end, tell us what you need. And then at that more advanced end of the spectrum, what else do you want to see? What else should we be testing? … What more could we be doing at the state [level]?”

In a separate presentation, Jonathan Blum, MPP, principal deputy administrator at CMS, said he’d also like to hear from physicians who haven’t yet joined accountable care organizations (ACOs). “For those that are not participating today, tell us what it would take to get you to participate,” he said. “Do the models have to be perfected, does the operation have to be perfected? Tell us really specifically what it would take.”

For ACOs, there is more to come this year, Fowler said, noting that last year the agency announced four new ACO models: “We had our fourth-generation advanced primary care model [Making Care Primary], a new dementia comprehensive care model called GUIDE [Guiding an Improved Dementia Experience], the multi-state [total cost of care] model AHEAD [Advancing All-Payer Health Equity Approaches and Development], and then in December we announced a maternal health model called TMaH [Transforming Maternal Health]. We will be working hard this year to implement those models.”

CMS announced one new model already this year — a behavioral health model called Integration in Behavioral Health — “and we have other new models in the pipeline … Over the next coming weeks, we hope to announce at least a couple more models,” she added.

These accountable care models are designed to make it easier to provide comprehensive care for patients, said Seshamani. She noted that when she was working as an ear, nose, and throat surgeon, “I had so many personal stories of my patients where I look back and I say, ‘How could we have taken care of that person differently?'”

For instance, “when I was in my residency training, there was an older gentleman who came in with a big tumor in his throat. And when he was going to surgery, I was reading through his clinic notes and it said that he drank 33 beers a day,” Seshamani said. “And I was like, ‘Is this an error?’ You know, [bad] doctor handwriting — ‘is it really three instead of 33?’ So in the pre-op area, I asked him. I said, ‘Sir, do you drink 33 beers a day?’ And he said yes.”

The patient “had this incredibly big surgery — removing the tumor, reconstruction — with zero nutrition in him to help him with healing,” she continued. “He ended up having alcohol withdrawal and a prolonged stay in the ICU needing to be detoxed. His wounds completely opened up, and we had to do this really complex wound packing. He had no family support. So then we’re trying to figure out, who’s going to do this complex wound packing and where is he going to go? And those are the kinds of examples where people aren’t being cared for as people.”

Accountable care, on the other hand, “seeks to do the exact opposite where you can say, ‘OK, what is your situation in your home? What are the various social factors and other factors that are playing into your health? And how can we make sure to address all of those in a way that makes sense for you?'” Seshamani added. “And that’s why the move that we have towards accountable care is so critical, so that we can really care for people as people, rather than just treating an individual disease.”