Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services (CMS) and Abe Sutton, CMS deputy administrator and Innovation Center director, on Tuesday announced the new strategic direction that they say will empower Americans to achieve their health goals and live healthier lives. The Innovation Center will focus on models that require downside risk and prioritize high-value care services.
The new effort aligns with the "Make America Healthy Again" campaign endorsed by President Donald Trump and Department of Health and Human Services Secretary Robert F. Kennedy Jr.
During a webinar on Tuesday to announce the initiatives, Dr. Oz said that CMS will protect the most vulnerable Americans by providing them access to lower cost and excellent care.
“I believe we have a generational opportunity to give people power over their health and to save our health care system from costs that are rising faster than our economy," he said, before turning the program over to Sutton to provide more information about the new strategy.
Sutton said the current health care system is facing unsustainable cost pressures and pouring resources into treating diseases rather than tackling the root causes and preventing them. This approach, he said, is costly and has resulted in poor outcomes. Six in 10 Americans live with at least one chronic disease and four and 10 struggle with multiple chronic diseases. Furthermore, he claimed that Medicaid is the number one expense for most states and the Medicare Trust Fund is projected to be insolvent by 2036.
“We have a meaningful opportunity to drive systematic change and help people stay healthier longer,” Sutton said.
The Innovation Center’s three-pronged strategy will focus on prevention of diseases by providing patients will easier access to evidence-based, complementary, and alternative medicine; increase patient access to information and tools for disease management and healthy living; and new Medicare and Medicaid programs that will “foster even playing fields and fair competition.”
Goal 1: Evidence-based prevention
Prevention of disease will be incorporated into every single model adopted by the Innovation Center, Sutton said. The focus will be on primary and secondary prevention to avoid or detect it earlier when it is easier to treat as well as tertiary prevention which will involve engagement with the management of chronic disease and minimize its impact on people. Models will emphasize physical activity and good nutrition to promote healthier lifestyles and slow disease progression. In addition, Sutton said the models will aim to provide patients with easier access to evidence-based holistic medicine approaches.
“Ultimately, we are interested in the outcomes that these preventive care interventions will drive to ensure they effectively meet their aims and save taxpayer dollars,” he said. “If providers and plans have the flexibility, incentives, and tools and patients have support to make lifestyle changes tailored to their needs, we hope to show that Innovation Center models can prevent the onset of disease, can improve function, health status, and well-being for participants, can reduce adverse events and acute care utilization, can slow or halt disease progression and can increase time at home and mitigate intensive long term care needs by addressing functional and cognitive decline.”
Goal 2: Giving patients better access to information, tools, and support
Individuals need relevant, usable data so they can better understand their health status, set realistic goals with their providers, avoid unnecessary out-of-pocket costs, and engage more activity in their care, according to Sutton. “Empowering people with the right information at the right time and in the right format isn't just helpful, it's essential to shifting the system from one that is reactive to one that provides proactive care,” he said.
Sutton said the Innovation Center is currently assessing several tools that will help patients make more informed decisions. These tools include patient-facing mobile applications and data transparency tools that provide insight into provider cost and performance. Possibilities include waivers that would support predictable cost-sharing for certain services, drugs, and devices so patients are motivated to use them.
Goal 3: Patient choice and competition in the health care markets
Sutton said the Innovation Centers wants to provide patients with more options for care and a health care system that incentivizes high-quality care. This will involve aligning incentives and flexibilities in Original Medicare, Medicare Advantage, and Medicaid to foster an “even playing field” and competition.
The goal is to encourage new provider types, such as independent and rural practices, to participate in the models.
“We often hear from providers and payers that engaging in value-based care has been overly complicated and that administrative burden is a major barrier,” Sutton explained. Therefore, the Innovation Center plans to simplify and standardize models, standardize quality measures, and improve benchmarking.
Future models will use advanced shared savings and prospective payments to support independent provider participation, increasing high-value coverage options in Medicare Advantage, promote site neutrality, and standardizing quality measures to reduce administrative burden.
Payment models, he said, that are found to reduce costs, will have a pathway into permanent Medicare, Medicaid, and CHIP programs. The Innovation Center will accomplish this by strengthening model design to require downside risk and prioritize high value care services and reduce low value care.
“It is through this lens that we will assess new and existing models with the intention of curbing Medicare and Medicaid spending, protecting our federal programs, and right sizing the focus of our health care system on our patients,” Sutton said.
Sutton also said the Innovation Center remains committed to value-based care and moving forward with health care payment and care delivery models that show the greatest promise for expansion. He said the innovation will update existing models and design new Original Medicare models that will leverage payments and regulatory flexibilities, such as waivers. “We’re going to expand our work to test improvements in Medicare Advantage and Medicaid,” he said.
For more on the new strategic direction, read the CMS announcement and a white paper by Sutton about the initiatives.