Medicare Ahead: Equity, Accountability, Sustainability

This is the third post in a four-part ACCCBuzz blog series on the hospital-at-home model. Before reading below, be sure to check out the first and second post in this series.

In keynote remarks during Modern Healthcare’s virtual briefing on Transforming Care Delivery with Hospital at Home, Meena Seshamani, MD, PhD, deputy administrator at the Centers for Medicare & Medicaid Services (CMS) and director for the Center for Medicare, characterized Medicare as “an accelerator of change throughout our healthcare system.”

Speaking on “The Future of Medicare,” Dr. Seshamani first set the federal healthcare program in context. Medicare’s power (the agency pays 1 in 5 healthcare dollars in the United States) and size (the agency partners with 1 million clinicians to provide care) are such that “the improvements we make to Medicare now can ripple across the healthcare economy,” she said.

Equity-Driven Solutions

Looking to the future, CMS is seeking to leverage the agency’s strength to advance health equity; drive high-quality, person-centered care; and promote the affordability and sustainability of the Medicare program. Dr. Seshamani emphasized that health equity is driven by the latter two pillars. Medicare’s approach to advancing health equity is two-pronged: improving operations and implementing specific policies to address equity. She highlighted the following agency actions for:

Improving operations

• Proposed that materials developed for Medicare beneficiaries are available in more languages.

• Proposed stronger oversight of Medicare plans and providers to ensure that beneficiaries can quickly and easily access the care they need.

• Worked to build the capacity of healthcare organizations and the workforce to reduce disparities. (Following congressional action, CMS is now funding more medical residency positions in hospitals that serve rural and underserved communities.)

Implementing specific policies to address equity

• Proposed that all Medicare Advantage Special Needs Plans screen for housing instability, food insecurity, and transportation for their enrollees.

• Sought comment on a new health equity index in Medicare Advantage plans so that the agency will have more clarity around where plans are delivering high-quality care to underserved populations.

Throughout her remarks, Dr. Seshamani emphasized the need to create more holistic, connected care models. The COVID-19 pandemic spotlighted this need, she said, which sparked more conversations about delivering care where people need it and the importance of meeting patients where they are. Connected, more inclusive care—for example, care that integrates services of community health workers and in-home providers—can help identify and resolve access barriers and support patients in maintaining health.

Accountable Care Organizations (ACOs) have shown that better care coordination (e.g., providing care not just within the four walls of a hospital or an office visit, but across the experiences of an individual) is key to keeping people healthy, said Dr. Seshamani. During the pandemic, the promise of ACOs became even more evident, she said. “We saw [the] Medicare Shared Savings Program [and] ACOs invest in care managers and community health workers that proved critical to support communities struggling to stay healthy during the pandemic.”

Committed to Value-Based Care

Medicare’s commitment to value-based care has never been stronger, she said. “We have a goal of 100 percent of people in traditional Medicare [to be] in a care relationship with accountability for quality and total cost of care by 2030.” In broad terms, Dr. Seshamani reiterated the Center for Medicare and Medicaid Innovation Center’s strategic vision. Driving the future of value-based care will be done through three aims:

1. Alignment. The current state in which multiple value-based models incentivize different quality measures with varying payment structures can create confusion and make it difficult to change how providers deliver care. Aligning these models will allow providers to focus on the most meaningful changes and create stability for Medicare beneficiaries to access the highest quality care. In terms of scaling value-based models, Dr. Seshamani noted that the Medicare Shared Savings Program is the largest value-based care program in the nation, affecting 11 million people who are cared for by more than 500,000 clinicians. Therefore, innovations are necessary within this program to create the largest impact.

2. Equity. More holistic care models present opportunities to address health disparities. The agency will re-examine its value-based programs to ensure equity is integrated in all models and will be exploring ways to increase participation among providers who serve rural and underserved communities.

3. Sustainability. Serving as a responsible steward of public funds is critical to protecting Medicare sustainability, Dr. Seshamani said. As such, the agency will require more data and transparency on how Medicare dollars are spent.

Where Does This Leave Technology and Innovation?

Though Dr. Seshamani spoke at a briefing that focused on care transformation through hospital-at-home models, her technology-related remarks largely focused on telehealth. She highlighted how the uptake of telehealth due to CMS’ waivers that were issued during the COVID-19 Public Health Emergency (PHE) and the successful adoption of telehealth technology resulted in increased access to care and improved quality of life for many.  

Additionally, Dr. Seshamani noted that following congressional action, CMS is permanently allowing Medicare beneficiaries to access mental and behavioral health via telehealth, including audio-only visits by phone, and its recent approval of enhanced payment for home dialysis services for people with end-stage renal disease.

At the same time, she called attention to technology and its potential to create disparities. As innovations are developed, consideration must be given to how technology can address disparities to access and care without creating others in the effort to improve equity.

The Acute Hospital Care at Home Program waiver is the first example of CMS providing this level of payment for care at home, said Dr. Seshamani. And the waiver remains in effect for the duration of the PHE. Once it ends, CMS’s legal authority to extend the program is limited.

As responsible fiscal stewards, “We want to evaluate all innovations [created] during the pandemic to move care upstream and keep people healthy,” said Dr. Seshamani. “I want to challenge innovators to not just replace an in-person visit with using audio-video technology, but to create technologies that will fundamentally drive better care, smarter spending, and healthier populations. Where can new technologies keep people healthy and out of the hospital? Where can they reach people who have thus far not been able to access care?”

Collaboration is Necessary

Dr. Seshamani concluded with a call for collaboration across all healthcare sectors. “We cannot achieve our goals to advance health equity, drive high-quality person-centered care, and promote affordability and sustainability without you,” she said. Thinking about these problems in silos will not render the solutions needed. “It’s going to take a coordinated multi-sector effort that bridges siloes across the healthcare ecosystem to create lasting change.”