At NAACOS Meeting, Gaus, Brooks-LaSure Discuss Equity, Payments, Messaging

A range of topics, including health equity, messaging about value-based care and accountable care organizations (ACOs), and thorny physician payment issues, were all part of a discussion during the first day of the NAACOS Fall Conference 2022.

After giving the opening plenary Thursday, CMS Administrator Chiquita Brooks-LaSure answered questions from Clif Gaus, ScD, president and CEO of the National Association of ACOs, as well as a few from the audience, starting with equity.

Nearly a year ago, CMS released its “refresh” of its Innovation Center’s strategy focused on streamlining model implementation and integration throughout the next decade and addressing social determinants of health by prioritizing inclusion of underserved populations and threading health equity throughout. As part of the Affordable Care Act, the Innovation Center (or CMMI) was created in 2010 and sought to transform Medicare and Medicaid into health systems more focused on value-based care.

In her plenary, Brooks-LaSure touched on the lessons included in a white paper from the past 10 years and strategies for the future, which envisions that by 2030, every Medicare beneficiary will be receiving their care from an ACO.

Those inside the health care industry may have talked about equity issues a decade ago, said Brooks-LaSure, but they didn’t use the word, because there was no “shared appreciation” of what it means. COVID-19 changed all of that, she said.

With health equity in the lexicon of health care, Brooks-LaSure said it needs to become sustainable so that it is not subject to political whims.

To move equity and other issues forward, she said Thursday, it means that “every time we're looking at a policy, we have to ask ourselves the question, are we only going to benefit the people who have the best access to health care coverage?” Programs have to be designed in such a way that those who are underserved can actually access them, she said, and in that regard, CMS is reexamining everything they are doing.

Partnerships, particularly with organizations that are what she called “health care adjacent,” can help health system executives and providers who feel stretched to help meet these new goals, Brooks-LaSure said.

Meeting the nutritional needs of patients who are food insecure is one example that could be helped by such a partnership, she said, while acknowledging that better, more uniform data are needed to achieve these goals, which requires an understanding of which interventions are the most effective and using funding in the most efficient way possible.

Turning to a different topic, Gaus spoke about the difficulty of communicating the message of ACOs and how they benefit Medicare to policy makers, and triggered some laughter and applause from the in-person audience when he said private Medicare Advantage (MA) plans appear “to get all the attention and have all the money,” adding, “it’s not an anti-MA question.”

“We feel like we're sort of this, in part, ‘lost child’ that is achieving everything that was asked of us, but not getting recognized for it, in public policy. So, I'm just curious, what do you think about that?” he asked, particularly in how ACO stakeholders can improve communications.

That is a topic under discussion at CMS, Brooks-LaSure said, saying the problem starts with the phrase value-based care, she said.

“That kind of language only resonates with a certain part of the health care system. People don't know what that means. Beneficiaries have no idea what that means. And if they do have a sense, usually it's a negative reaction. That means you're going to cut my benefits. And so I think that we need to talk about accountable care in a very different way.”

One communication change to make is to present the issues through the eyes of beneficiaries, she said.

“I think it's really important for you all as you are showing your leadership, your members of Congress, your state officials, to really talk about it through the lens of what it means for the people that you're serving,” she said, using the example of an integrated service that combines pediatric, mental health, and obstetric/gynecologic services in 1 location in order to better serve mothers and children.

Gaus asked about the challenges she foresees to accomplishing the goal of having 100% of Medicare beneficiaries in an ACO by 2030, and Brooks-LaSure again referred to communicating the message in a way that it is received as intended. This means making sure patients see ACOs as a good thing and not threatening, making sure the underserved are included, and aligning incentives such that physicians want to join.

At the mention of incentives, Gaus brought up looming payment cuts for providers. A 5% bonus for physicians who participate in advanced alternative payment models is due to expire at the end of this year, unless Congress extends it.

In addition, CMS’ proposed 2023 Medicare Physician Payment Schedule includes another range of payment cuts. Under the proposed rule, CMS proposed a nearly 4.5% cut in the so-called conversion factor for each relative unit, which is the calculation for how providers are paid. In addition, specific services are slated for reductions, and there would be mandatory cuts under sequestration rules; those cuts were halted for the past 2 years because of the pandemic but are slated to resume.

Brooks-LaSure said the bonus payment is a part of the president’s budget, but noted that there are “so many competing priorities in health care and across the government,” which is why effective messaging is so important, she said.