CMS Administrator Seeking Docs’ Input on How to Improve ACOs

AUSTIN, Texas — The Biden administration wants to hear from clinicians and other stakeholders about how to improve efforts to switch from “volume” to “value” when it comes to paying providers, Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure said Thursday.

The hope with the Medicare Shared Savings Program and other Medicare accountable care organizations (ACOs) — which are groups of doctors, hospitals, and other healthcare providers who come together to give coordinated high-quality care to their Medicare patients — “is really around making sure that we’re creating the right incentives,” Brooks-LaSure told MedPage Today during a briefing here at the annual conference of the Association of Health Care Journalists.

“So we do want to continue to engage stakeholders to figure out how we encourage that. I put the Medicare Shared Savings Program in the same bucket as a lot of our work on ACO REACH and other models where we are willing to engage to and really make sure that it’s a value proposition to the people as well as the providers,” she added.

Brooks-LaSure also was asked how she felt about private equity firms partnering with provider organizations to provide care to Medicare patients.

“We want to make sure we have accountability in what is happening and make sure that the dollars are being used to deliver care,” she said, adding that CMS wants to make ACOs attractive, “particularly to safety net providers.”

ACOs were one of several subjects Brooks-LaSure discussed at the press briefing, which was part of a conference involving more than 500 healthcare journalists. She also was asked about CMS’s decision not to reimburse Medicare beneficiaries for use of the Alzheimer’s drug aducanumab (Aduhelm) unless the patient is part of a clinical trial.

Brooks-LaSure said the situation with Aduhelm was “unique,” adding that it is her agency’s “distinct responsibility” to decide whether to cover a treatment offered to Medicare patients, “and it’s our responsibility as part of that process to determine whether something is reasonable and necessary for the treatment of the illness in this case.”

Although the agency often makes these kinds of determinations for FDA-approved devices, “it has not been something we’ve been asked to do on the drug side,” she said. In the case of Aduhelm, CMS reviewed 10,000 comments and “we met with anyone who asked us for a meeting and had stakeholder engagements. And then we went through a process with a team of clinicians and civil servants to make a decision based on that standard.”

The Aduhelm decision “isn’t a referendum on any decisions that we might make in the future,” said Brooks-LaSure. “We just haven’t seen this before, and we don’t expect to very often.”

Brooks-LaSure also was asked about concerns that some people who newly qualified for Medicaid during the pandemic will be dropped by states from the Medicaid rolls once the public health emergency ends, which could happen as soon as July. “This is one of the most important issues for CMS,” she said. “The entire agency is focused on maintaining the coverage levels that we currently see, because we are at record levels.”

The agency’s Medicaid team — and its team for the Affordable Care Act’s insurance marketplace — “are working with states to try to give them clarity about the flexibility that they have,” she added. CMS is encouraging states not to rush when they make “redeterminations” after the public health emergency ends, so they can make sure people stay on Medicaid, or move into marketplace coverage if they’re eligible.

“I would say we’re also trying to work with other partners, like health plans, providers, and other organizations, to make sure that we hold on to this coverage,” she said.

Another reporter asked Brooks-LaSure whether she would do anything about the Medicaid wage index for rural hospitals, whose payments per procedure run 30% below the national average.

“We do as an agency care very much about what is happening in our rural areas,” said Brooks-LaSure. Although CMS does have some flexibility in this area, “a lot of our rules are set by requirements we have from Congress,” so that’s where many changes would have to come from, she added.