Most people think of CMS (Centers for Medicare & Medicaid Services) as an insurance company that covers individual services provided by physicians, FQHCs, hospitals, and other health care providers. Some people even think of it as a policy-writing agency for Medicare. It is true that CMS reimburses providers for services to millions of individual beneficiaries. However, since the Affordable Care Act came into action in 2010, CMS has been developing focused payment strategies that shift from fee for services to value-based care and a focus on population health.
Today, CMS’s second-highest strategic priority is prevention and population health. To this day, the agency is engaged in numerous activities to promote effective prevention of chronic diseases and not just its treatment.
In 2011, the federal government reported that fewer than half of all adults aged 65+ were regular in checking the core set of recommended preventive services. The Affordable Care Act took a big step towards improving the access to preventive care by eliminating out-of-pocket costs for these preventive services in most insurance markets. This resulted in guaranteed access to preventive services like diabetes screening and cervical cancer screening to almost 137 Million Americans without cost-sharing.
Despite improved access to care, the use of preventive services among seniors with traditional Medicare coverage has not changed significantly. There are several hindrances that inhibit the greater uptake of preventive services. A 2014 survey reveals that only 43% of adults were aware of the new clinical preventive benefits provided by the Affordable Care Act. Of those who were aware of the services, 18% cited cost as a barrier, even though the Affordable Care Act eliminated co-payments for preventive services.
Another obstacle is that many Americans believe that preventive services are not important. Thus, even though many cost barriers have been removed, many Americans still might not perceive preventive services as valuable to their health and well-being. This mindset needs to change.
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 address this issue, CMMI has developed 2 payment models:
(1) The Million Hearts Cardiovascular Risk Reduction Model:
This model associates payment with population-based risk reduction. It is expected to reach over 3.3 million Medicare fee-for-service beneficiaries and involve nearly 20,000 health care practitioners by December 2021.
(2) The Medicare Diabetes Prevention Program:
This program ties payments to the achievement of weight loss through evidence-based lifestyle intervention.
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.
These path-breaking 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.