CMS Turns an Ear to Population Health

By David A. Kindig, MD, PhD

Last month I was privileged to be part of a group invited to the federal Center for Medicare and Medicaid Innovation (“Innovation Center”) to discuss population health models and opportunities. Why would the federal agency with the overwhelming job of controlling health care costs and implementing health reform be concerned about this?

The reason is that the Centers for Medicare and Medicaid Services (CMS) is viewing its approach to health improvement through the lens of the Triple Aim, with its Innovation Center being a new engine for revitalizing and sustaining Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) and ultimately, for improving the health care system for all Americans.

Under the Affordable Care Act, with active guidance from CMS leadership, the Innovation Center has substantial resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that promote better health and deliver better health care at lower cost.

The Innovation Center organizes its work in three major areas:

• Patient Care Models: The right care at the right time, in the right setting – every time.
• Seamless Coordinated Care Models: Coordinating Care to Improve Health Outcomes for Patients.
• Community and Population Health Models: Keeping families and communities healthy.

Much of the early work of the Center has been in the first two areas (for example with the recently released ACO regulations), but this “listening session” was intended to get feedback and ideas for the third area. The focus of this third area is “to improve the health of populations – either defined geographically (health of the community), clinically (health of those with specific diseases), or by gender, race/ethnicity, or age (health of those experiencing disparities).” As stated in the materials provided to session participants, the Center will select models for testing effective community and population health approaches and interventions to improve health care quality and decrease costs for inclusion in their portfolio, with an emphasis on prevention and wellness programs which are both clinical and community-based and focused on primary and secondary prevention of chronic diseases such as cardiovascular diseases, diabetes, cancer and mental illness.  

The meeting was led by Dr. Richard Gilfillan, the Innovation Center Acting Director, and Dr. Anand Parekh, Deputy Assistant Secretary for Health and Acting Director of the Population Health Models Group. The group of 30 assembled represented a wide variety of stakeholders. The conversation was stimulating and wide ranging, and it was apparent that the Center staff were actively engaged with the group in exploring challenges and opportunities.

Much of the discussion focused on how broad the population health model should and could be for CMS, given their primary responsibilities in medical care cost and quality. Many, including myself, argued that the model adopted should be a broad one, recognizing the multiple determinants of health. We argued that it would be a mistake to see population health as solely traditional chronic disease management, and as primarily focused on individual behavior change. It will be a challenge for CMS to go too far upstream, in part because they are required by law to only fund and test demonstrations which are likely to reduce Medicare or Medicaid expenditures (over an apparently unspecified time period) and in part because this would involve funding different kinds of activities and organizations than they traditionally work with. Given this, it is not clear to what degree their demonstrations would be able to reach into the social determinants.

On the other hand, it was pointed out that if the goal is to leverage broad population health metrics including disparity reduction, effective approaches cannot be limited to health care alone. It is well known and CMS staff acknowledge that substantial aspects of individual behavior change are dependent on the social context. Even if the CMS work focuses on behavioral risk factor reduction to prevent chronic conditions and their resultant morbidity and costs, perhaps demonstrations can include components which encourage or require health care organizations to partner with public health and other community organizations to leverage the broader and more upstream determinants. One approach might be to test funding for community health teams and broadly defined prevention specialists as has been under way in Vermont. Another might be to be provide community health systems with epidemiological and cost effectiveness training and technical support to be sure that the interventions are on target for broad population health impact.

The challenges are great, but I am pleased that this critical federal agency is “listening” to population heath advocates as they design their work. And it is particularly encouraging for population health proponents to hear an agency  traditionally focused exclusively on health care express interest in investing in prevention efforts and in incentivizing health care providers to become engaged in community prevention efforts. Stay tuned for the upcoming CMS announcement of funding opportunities to test population health models with the potential for metrics improvement and cost savings. If you have a model or idea you think they should be considering, you can submit it here.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Helene Nelson]

It's nice to hear that CMS is using the triple aim framework. Also - good job, Dave, on encouraging CMS to take a broad lens on determinants of health!

Gratuitously I add: The triple aim would also be great for the UW SMPH to consider as an integrating framework for its work.