Abstract
In 2015, Sylvia Burwell, Secretary of the US Department of Health and Human Services, set a new goal for Medicare and the Centers for Medicare & Medicaid Services (CMS). By 2018, she declared, at least 90% of all Medicare fee-for-service payments should be based on quality or value. In other words, by 2018, most CMS payments will no longer be based on the volume of services delivered (ie, traditional fee for services) but will instead be based on models of delivery that promote meaningful outcomes in care and health.
Many people think of CMS as an insurance company that covers individual services provided by physicians, hospitals, and other health care providers or as a policy-writing agency for Medicare and the other government-funded health care coverage that it administers (ie, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace created by the Affordable Care Act). CMS does reimburse providers for services to millions of individual beneficiaries. However, since the Affordable Care Act was passed in 2010, CMS has been developing focused payment strategies that shift from fee for services toward value-based care (ie, health care with meaningful patient outcomes) and a focus on population health. Today, prevention and population health are CMS’s second-highest strategic priority (the first is better care and lower costs). To this end, the agency is engaged in numerous activities to promote effective prevention of chronic diseases, not just treatment.
Prevention and Population Health Innovation at CMS
Although all CMS agencies (called “centers”) incorporate aspects of prevention and population health into their portfolios, one group at CMS, the Prevention and Population Health Group, is focused on this work. The Prevention and Population Health Group is located in the CMS Center for Medicare and Medicaid Innovation (CMMI), which was established by the Affordable Care Act in section 1115A of the Social Security Act. 1 As the research and development arm of CMS, CMMI develops and implements payment and service delivery models to decrease cost and improve quality of care for CMS beneficiaries. Under the same section of the Affordable Care Act that established CMMI, the US Department of Health and Human Services Secretary has the authority to expand the scope and duration of models that she determines will improve the quality of care, will reduce net spending, and will not deny or limit coverage or provision of benefits. By exercising these authorities, the Prevention and Population Health Group contributes to CMS’s and the US Department of Health and Human Services’ efforts toward a healthier population, and it pushes the boundaries for what prevention looks like in a large public insurer. A notable example is the Accountable Health Communities Model, the first initiative from CMS to take an upstream public health approach by systematically screening beneficiaries for health-related social needs in a clinical setting. 2
Two of CMMI’s prevention- and population health–focused innovations are of special interest because they establish incentives for true improvements in population health, instead of merely paying for individual services, such as the preventive and screening services that CMS now covers for Medicare beneficiaries. 3 For CMS, learning how to pay for improvement in population health is challenging, but the agency is making real progress. In this article, we describe 2 models that are shifting CMS spending from reimbursement for individual services toward value-based preventive services tied to meaningful health outcomes. They are paving the way toward better preventive care and, in time, better health for the nation.
The Case for Value-Based Prevention
In 2011, the federal government reported that fewer than half of all adults aged >65 were up-to-date on the core set of recommended preventive services. 4 The Affordable Care Act took a big step toward improving access to preventive care by eliminating out-of-pocket costs for these preventive services in most insurance markets. As a result, 137 million Americans with health care insurance now are guaranteed access to preventive services, such as cervical cancer screening, tobacco use counseling, and diabetes screening, without cost sharing or copayments. 5
Despite improved access to care, the use of preventive services among seniors with traditional Medicare coverage has not changed significantly. 6 Several obstacles still may be inhibiting greater uptake of preventive services. In a 2014 survey, only 43% of adults were aware of the new clinical preventive benefits provided by the Affordable Care Act. 7 Of those who were aware of the services, 18% cited cost as a barrier, even though the Affordable Care Act eliminated copayments for preventive services. Another obstacle is that many Americans believe that preventive services are not important. In the 2013 Kaiser Women’s Health Survey and 2013 Kaiser Men’s Health Survey, 21% of adults said that preventive services were not that important to them. 8 Thus, although many cost barriers have been removed, many Americans still might not perceive preventive services as valuable to their health and well-being.
How providers are reimbursed for preventive services may contribute to this perception and lack of uptake among patients. Traditionally, payment strategies to clinicians have emphasized treatment and individual services instead of disease prevention. Clinicians who provide preventive services are still paid primarily through reimbursement for individual preventive services to their patients, not for affecting the overall health of their patients. For example, although Medicare and private payers now can reimburse providers for preventive colonoscopies, those payments do not reward providers for reducing the rate of colorectal cancer in their patient populations. Even after the Affordable Care Act’s insurance reforms, payments for prevention still emphasize individual services (eg, clinical screenings) and do not provide an incentive for the provider to improve the status of their patients or promote long-term preventive actions by patients. For example, many patients who have a negative colorectal cancer screening may not receive the follow-up care needed to lower their future risk of colon cancer, and some patients with positive colorectal cancer screening tests do not follow up. One study found that 41% of patients with positive colorectal cancer screening tests failed to receive follow-up testing. 9 Shifting the paradigm of preventive care requires CMS and other payers to provide incentives beyond individual services to broader value-based and lifestyle interventions that can change population outcomes.
To nudge this needed shift, CMMI developed 2 payment models: (1) the Million Hearts Cardiovascular Risk Reduction Model (the Million Hearts Model), which associates payment with population-based risk reduction, 10 and (2) the Medicare Diabetes Prevention Program, which ties payments to achievement of weight loss through an evidence-based lifestyle intervention. 11 CMS collaborated with sister agencies such as the Centers for Disease Control and Prevention (CDC) to develop these population health models, and they are good examples of how CMMI is using the Medicare payment structure to improve prevention and population health.
The Million Hearts Model
Cardiovascular disease, the leading cause of death in the United States, affects 1 in 3 people and costs the national health care system >$315 billion annually. 12 Announced in 2015, the Million Hearts Model provides incentives for providers to reduce the 10-year risk of cardiovascular disease among their high-risk patients. The Million Hearts Model goes beyond merely screening people for cardiovascular disease risk factors (eg, high blood lipids, hypertension) and instead uses the American College of Cardiology/American Heart Association Longitudinal Atherosclerotic Cardiovascular Disease Risk Calculator, a widely accepted risk prediction algorithm, to generate a patient’s 10-year risk score for myocardial infarction or stroke. Health care providers can then use the risk score to identify the main drivers of risk and show patients how they can lower their risk through health behavior changes, such as smoking cessation, pharmacologic therapies targeting blood lipids, and blood pressure control. Health care providers and patients can then decide which interventions will lower their risk. This approach is much different from the current Medicare practice of simply covering the screening tests used to identify individual risk factors. Under the Million Hearts Model, health care providers can assess cardiovascular disease risk in its totality and be compensated through tiered financial incentives based on the degree of risk reduction achieved in their entire high-risk patient population. The greater the reduction in the patients’ composite 10-year risk, the greater the financial incentive payments (Table). By tying payments to risk reduction across the entire high-risk patient population, the Million Hearts Model rewards health care providers for population-wide, rather than individual, health improvement. 10
Two models of value-based preventive care at the Centers for Medicare & Medicaid Innovationa
Abbreviation: CDC, Centers for Disease Control and Prevention
The Million Hearts Model will launch in January 2017 as the largest prevention-focused randomized controlled trial ever released by CMS. Participating organizations were announced in July 2016 and include 516 practices in 47 states, Puerto Rico, and the District of Columbia. Randomization resulted in 260 organizations assigned to the intervention group and 256 organizations assigned to the control group. The Million Hearts Model will be implemented during the next 5 years. 10
The Medicare Diabetes Prevention Program
Type 2 diabetes affects nearly 30 million Americans, and an estimated 86 million Americans are prediabetic. An estimated $1 of every $3 Medicare dollars is spent caring for Medicare beneficiaries with diabetes. 13 From 2013 to 2015, CMMI enrolled >7000 Medicare beneficiaries in a model to test the effectiveness of CDC’s Diabetes Prevention Program. The Diabetes Prevention Program is an evidence-based lifestyle intervention program that prevented the onset of type 2 diabetes in several clinical trials. 14,15 In March 2016, based on the results of the model test, the CMS chief actuary certified the Diabetes Prevention Program model as cost saving for Medicare. 16 After certification, Secretary Burwell of the US Department of Health and Human Services authorized expanding the scope and duration of the Diabetes Prevention Program model within Medicare, marking the first prevention model to be expanded under section 1115A authority. 17
The Medicare Diabetes Prevention Program expansion, as described in the proposed rule published in summer 2016, will be the first community-based preventive service that focuses on changing lifestyle and behavior, such as diet and exercise, at CMS. 18 The Medicare Diabetes Prevention Program will be implemented in 2018 as a preventive service, which means that eligible prediabetic seniors will have access to this program without incurring out-of-pocket costs. The 12-month core benefit will be offered by organizations via an evidence-based curriculum approved by CDC to deliver health coaching to beneficiaries. 19 For the first time, CMS will reimburse health care providers for achieving critical milestones in prevention—namely, weight loss and maintenance (Table). Payments will be weighted toward achieving a minimum of 5% weight loss from baseline during the first 6 months of the core benefit, an outcome that can greatly reduce the progression to diabetes. 15 During the second 6 months of the core benefit and beyond, monthly maintenance sessions will be reimbursed only if the beneficiary maintains at least a 5% weight loss.
Through this payment structure, the Medicare Diabetes Prevention Program expansion aims to create strong incentives for Diabetes Prevention Program organizations and coaches to keep seniors on track to achieve these milestones. The model expansion also will establish a new class of preventive service suppliers, CDC-recognized organizations employing lifestyle coaches to deliver the intervention in community and health care settings. Many of these organizations will be new to Medicare, representing a shift toward the delivery of upstream preventive care that addresses lifestyle and behavior modification in community-based settings.
Better Care and a Healthier Population
The Million Hearts Model and the Medicare Diabetes Prevention Program expansion mark new ways of paying for preventive services. Instead of reimbursing providers for individual preventive services, these models offer incentives to providers to address the health of their whole patient population and use new methods of delivery, such as lifestyle coaches in community-based settings. These innovations offer an opportunity for CMS to test payment models that emphasize payment for population health outcomes rather than just individual outcomes, with the goal of better care and a healthier population.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.