CMS announces all-payer model for states

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The Centers for Medicare and Medicaid Services has released the voluntary States Advancing All-Payer Health Equity Approaches and Development Model in which participating hospitals would receive a fixed payment amount in advance of a prospectively set budget per year.

The States Advancing AHEAD Model aims to better address chronic disease, behavioral health and other medical conditions by testing a state's ability to improve the overall healthcare management of its population.  

A primary role of states participating in the AHEAD Model will be to leverage existing relationships to recruit and partner with hospitals for purposes of the hospital global budgets. 

Payments are for both Traditional Medicare and Medicaid, while other payers may also choose to pay participating hospitals based on a global budget for their enrolled populations or specific patient groups, CMS said.

Additionally, states will recruit primary care providers to participate in multi-payer primary care transformation, which will include increased investment by Traditional Medicare and an advanced primary care program aligned between Medicaid and Traditional Medicare. 

Other payers may also choose to align with this advanced primary care program by offering prospective care management payments, rewarding performance on aligned quality measures and focusing provider efforts on behavioral health integration and addressing health-related social needs. 

CMS will issue awards to up to eight states. Each state selected to participate in the AHEAD Model will have an opportunity to receive up to $12 million from CMS to support state implementation. 

CMS is offering a longer pre-implementation, or planning period, for states that need additional time to prepare for the care redesign required under the Model. CMS is also testing the model over a longer period to allow time for early investments in primary care services and enhanced care coordination to result in better health and lower spending. 

Recognizing that some states are more ready than others to implement change, states interested in participating in the model may apply during two different application periods and elect to participate in one of three cohorts with staggered start dates and performance years.

The Notice of Funding Opportunity, which includes the specific application requirements, will be released in late fall 2023. States will have 90 calendar days to apply for a cooperative agreement award during this first application period. 

The second NOFO application period is anticipated to open in spring 2024, with a 60-day application period. States must apply to the NOFO during the application period to participate in the AHEAD Model. 

The pre-implementation period is scheduled to begin for the first cohort in summer 2024. The model performance period for states is scheduled to begin in January 2026 or January 2027, depending on the cohort, and the model will conclude for all state participants in December 2034.

WHY THIS MATTERS

States have existing relationships with hospitals, primary care providers, payers, local government and communities and nonprofit organizations, which can be leveraged to improve population health and advance health equity, CMS said. 

Under the AHEAD Model, participating states will take accountability for healthcare spending, population health and health equity improvements. 

CMS plans to partner with states to redesign statewide and regional healthcare delivery to improve the total population health of a participating state or region by improving the quality and efficacy of care delivery, reducing health disparities and improving health outcomes.

State participants will partner with hospitals and primary care practices to redesign care. 

Each participating state will have a Medicare total cost of care growth target in the AHEAD Model determined by CMS and participating states during the pre-implementation period. This target should incentivize states to control unnecessary spending by reorienting care towards prevention and providing care in the safest, lowest acuity setting. 

The all-payer cost growth targets, which will be set by states, will encourage states to align payer efforts to slow the growth of healthcare costs while driving transformative change, CMS said. States will also have a Medicare and an all-payer primary care investment target to enhance primary care delivery.

AHEAD also includes specific payment models for participating hospitals and primary care practices. 

Specifically, the AHEAD model will:

• Focus resources and investment on primary care services, giving primary care practices the ability to improve care management and better address chronic disease, behavioral health and other conditions.
• Provide hospitals with a prospective payment stream via hospital global budgets, while including incentives to improve beneficiaries' population health and equity outcomes.
• Address healthcare disparities through stronger coordination across healthcare providers, payers and community organizations in participating states or regions.
• Address the needs of individuals with Medicare and/or Medicaid by increased screening and referrals to community resources like housing and transportation.

THE LARGER TREND

Under the AHEAD Model, participating states will be better equipped to promote health equity, increase access to primary care services, set healthcare expenditures on a more sustainable trajectory and lower healthcare costs for patients, CMS said. The model aims to increase screening and referrals to community resources such as housing and transportation to address social drivers of health.

This builds on lessons learned from existing state-based models, including the Maryland Total Cost of Care Model, the Vermont All-Payer ACO Model and the Pennsylvania Rural Health Model, CMS said. 

The model's flexible framework capitalizes on existing state innovations while testing interventions across all states. 

The AHEAD Model represents the next iteration of the CMS Innovation Center's multi-payer total cost of care models. States participating in AHEAD will be accountable for quality and population health outcomes while reducing all-payer avoidable healthcare spending to spur statewide and regional health care transformation.

ON THE RECORD

"In our current healthcare system, fragmented care contributes to persistent, widening health disparities in underserved populations," said CMS Administrator Chiquita Brooks-LaSure. "The AHEAD Model is a critical step towards addressing disparities in both healthcare and health equity while improving overall population health."

"Primary care is the foundation of a high-performing health system and essential to improving health outcomes for patients and lowering healthcare costs," said Deputy CMS Administrator and Innovation Center Director Liz Fowler. "For that reason, the CMS Innovation Center has invested significant time and resources over the years testing models to strengthen primary care and improve care coordination and linkages to organizations that address health-related social needs." 

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org