Catalyzing Innovative Health System Transformation: An Opportunity Agenda for the Center for Medicare & Medicaid Innovation (2022)

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5 CMMI PRIORITY ACTIONS AND IMPLEMENTATION CONSIDERATIONS This section of the Special Publication presents a series of pri- mary considerations for CMMI. The considerations are intended to underscore the key operational changes attendees at the conven- ings on multi-payer alignment on value-based care and collect- ing 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 prog- ress 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 ac- tion. 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-stake- holder landscape with various interests and needs. Namely, they urged CMMI to consider the importance of: 25 

26 | Catalyzing Innovative Health System Transformation 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 ef- forts 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. BOX 2 Center for Medicare & Medicaid Innovation Strategic Objectives In late 2021, CMMI released its Strategic Refresh. To “achieve equi- table outcomes through high-quality, affordable, person-centered care,” CMMI established five strategic objectives with associated aims. The objectives are as follows: 1. Drive accountable care: Increase the number of people in a care relationship with accountability for quality and total cost of care. 2. Advance health equity: Embed health equity in every aspect of CMS Innovation Center models and increase focus on under- served populations. 3. Support care innovations: Leverage a range of supports that enable integrated, person-centered care such as actionable, practice-specific data, technology, dissemination of best practices, peer-to-peer learning collaboratives, and payment flexibilities. 4. Improve access by addressing affordability: Pursue strategies to address health care prices, affordability, and reduce unnec- essary or duplicative care. 5. Partner to achieve system transformation: Align priorities and policies across CMS and aggressively engage payers, purchas- ers, providers, states, and beneficiaries to improve quality, achieve equitable outcomes, and reduce health care costs. PREPUBLICATION COPY - Uncorrected Proofs 

CMMI Priority Actions and Implementation Considerations | 27 • 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 CMS public engagements, statements, and docu- ments. With a defined cadence and partnerships with stake- holder organizations, help engage the stakeholder commu- nity by communicating the importance of resolving priority stakeholder concerns, providing updates on CMMI develop- ments and progress, and announcing model specifics such as risk adjustment, benchmarks, and targets (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care and Stra- tegic Objective 5 – Partner to Achieve System Transformation). • Collecting Data to Ensure Equity in Payment Policy. Reem- phasize the key actions and steps that CMMI will take and asked of payers, providers, and purchasers to prioritize eq- uity, 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 com- munities (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 stake- holder engagement and input to provide clear and actionable guidance, targets, and metrics, to encourage further synergis- tic 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 im- pact of efforts to align the economic incentives of provid- ers with population health and risk-based payments. The roadmap could also outline plans for CMMI 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 PREPUBLICATION COPY - Uncorrected Proofs 

28 | Catalyzing Innovative Health System Transformation 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 Objec- tive 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. Devel- op, identify, and communicate the approaches, activities, and timelines used to meet targets through a comprehen- sive and actionable roadmap (e.g., providing culturally ap- propriate guidance through training to empower health and health care stakeholders to clarify perceived and real bar- riers 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 Transfor- mation). 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 measure- ments to focus on the most important performance elements and use core measures with beneficiary, payer, and caregiv- er groups to support and track the alignment required to en- able 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- develop core datasets that measure performance on equity dimensions and display significance to field stakeholders, as well as patients, families, advocates, and communities. PREPUBLICATION COPY - Uncorrected Proofs 

CMMI Priority Actions and Implementation Considerations | 29 These measures, which should be both universal and tar- geted, could comprehensively account for, assess, and eval- uate underserved populationsʼ 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 edu- cation, 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 al- ternative 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, ob- jectives, 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 com- mitments from decision-makers to work on transitioning toward value-based 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. Pro- vide more substantial incentives to drive multi-stakeholder collaboration to collect equity data while providing learn- ing tools, technical assistance, mechanisms, and funding for states, providers, and communities. States could use these resources to develop, coordinate, and lead innova- tions while proactively and continuously coordinating com- PREPUBLICATION COPY - Uncorrected Proofs 

30 | Catalyzing Innovative Health System Transformation munity 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 pro- vide the collected data, documented community-based best practices and experiences, and align state, provider, and community stakeholders to test, implement, and craft com- munity-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 sta- tus, sexual orientation, gender identity, and education, as well as the fee for service chassis (aligns with CMMI’s Stra- tegic 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 ap- proaches toward strengthening the system capacity required to adopt alternative payment models, collect health data, and le- verage 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. Addi- tionally, this support would leverage personalized partner- ships, scaling support, technical assistance, and continu- ous engagement and progress tracking to scale the adoption of APMs further. This engagement would also help CMMI rapidly incorporate learned payment, design, and imple- mentation lessons. CMMI could also support communities, employers, states, groups, and systems currently making advanced progress on implementing aligned multi-payer value-based care models or alternative payment models within its statutory authority (aligns with CMMI’s Strategic Objective 1 – Drive Accountable Care, Objective 3 – Support Care Innovations, Strategic Objective 4 – Improve Access by Address- PREPUBLICATION COPY - Uncorrected Proofs 

CMMI Priority Actions and Implementation Considerations | 31 ing Affordability, and Strategic Objective 5 – Partner to Achieve System Transformation). • Collecting Data to Ensure Equity in Payment Policy. De- velop 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 time- ly 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, 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 to- ward value-based care and facilitate the efficient and compre- hensive 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 ad- vanced progress has been made on multi-payer alignment toward value-based care to accelerate progress and agree upon bi-directional efforts to address obstacles 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 PREPUBLICATION COPY - Uncorrected Proofs 

32 | Catalyzing Innovative Health System Transformation Objective 4 – Improve Access by Addressing Affordability, and Strategic Objective 5 – Partner to Achieve System Transforma- tion). • Collecting Data to Ensure Equity in Payment Policy. Test innovative and creative strategies that incentivize and fa- cilitate the adoption of health data collection in multiple contexts and diverse, intersectional populations. These in- novations could, through evidence-based mechanisms, provide promising practices for measurably reducing bias and care malpractice, improving care outcomes, and driv- ing investments into the community and social drivers of health. These learnings could then be incorporated into fu- ture CMMI efforts and disseminated across stakeholders collaborating with CMMI (aligns with CMMI’s Strategic Objec- tive 2 – Advance Health Equity, Objective 3 – Support Care In- novations, 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 ac- tions 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 sug- gested to adopt a multi-stakeholder approach emphasizing meaningful and continuous engagement. This approach 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 adop- tion of alternative payment models and centering the collec- tion, sharing, and application of health equity data. Under- scored throughout this emphasis was the potential impact of PREPUBLICATION COPY - Uncorrected Proofs 

CMMI Priority Actions and Implementation Considerations | 33 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 En- sure Equity in Payment Policy discussion, attendees empha- sized the importance of a nuanced understanding of intersec- tionality and diversity of critical factors and characteristics for consideration in collecting data to ensure equity in pay- ment 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 con- text, 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 hous- ing. 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 im- pact on their health and well-being. 3. Expanding CMMI activities and impact. CMMI could in- tegrate, expand, and match its offerings and tailor its ap- proaches and mechanisms to different stakeholders and con- texts 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- ations presented through the Catalyzing Innovative Health Sys- tem Transformation initiative are intended to align, support, and inform the implementation of the CMMI Strategic Refresh. These items provide ideas for initiatives in which CMMI could accomplish its strategic objectives in a cross-cutting fashion to achieve equi- PREPUBLICATION COPY - Uncorrected Proofs 

34 | Catalyzing Innovative Health System Transformation table outcomes through high-quality, affordable, person-centered care. They also outline how CMMI could leverage the priority ac- tions and the implementation considerations to generate new pro- grams and methodologies that innovate not only in terms of pro- gram design, outcomes, or elements but also in terms of CMMI’s ability to unite, coordinate, and impact multiple stakeholders and beneficiaries at various scales. PREPUBLICATION COPY - Uncorrected Proofs