The following comments were submitted to the Centers for Medicare & Medicaid Services, by Richard Besser, MD, RWJF President and CEO, in response to the agency’s request for comments.
The Robert Wood Johnson Foundation (RWJF) is pleased to provide comments on the new direction that the Center for Medicare and Medicaid Services Innovation (Innovation Center) is considering to promote patient-centered care; test marketing reforms that empower beneficiaries as consumers; provide price transparency; and increase choices and competition to drive quality, reduce costs, and improve health outcomes. The Robert Wood Johnson Foundation (RWJF) is working to build a Culture of Health nationally, where everyone has a fair and just opportunity to live the healthiest life possible, and we recognize that promoting innovation and learning is central to our mission.
We are working to improve health and well-being together with partners across the country, many of whom contributed to these comments. We would like to recognize important input from various organizations including: The Center for Healthcare Strategies, State Health and Value Strategies at Princeton University, the Altarum Institute, Health Quality Advisors, American Institutes for Research, the Data Across Sectors for Health program, the John Snow Institute, the University of Chicago Finding Answers program, ReThink Health, Community Catalyst, the George Washington University, the National Safety Net Advancement Center, Catalyst for Payment Reform, and the Network for Regional Healthcare Improvement.
While each organization provided input to this response, these comments reflect the views of RWJF and not necessarily those of the organizations cited above.
Innovation Center Guiding Principles
RWJF applauds the Innovation Center for considering guiding principles as it evaluates decisions for new directions. These include choice and competition in the marketplace; provider choice and incentives; patient-centered care; benefit design and price transparency; and transparent model design and evaluation. We believe that these are positive approaches to driving improvements in heath and health care. However, we are submitting additional possible guiding principles for the Innovation Center’s consideration and offering furthering suggestions about patient-centered care.
Advancing Health Equity
RWJF believes that working to reduce racial and ethnic disparities in health and valuing diverse perspectives including those of historically excluded and marginalized groups is critically important to advancing health and needs to be at the forefront of the Innovation Center’s actions.1 As mentioned earlier, we believe this means that everyone has a fair and just opportunity to be healthier. Health equity also requires addressing obstacles to health such as poverty, discrimination, and their consequences, and increasing opportunities such as good jobs with fair pay, quality education and housing, safe neighborhoods, and—most immediately relevant to the Innovation Center—health care. Without a specific focus on health equity, payment and delivery system reform innovations can exacerbate health disparities.2 States can play a major role in fostering health equity through payment and delivery system reform efforts. We would like to refer the Centers for Medicare & Medicaid Services (CMS) to the recently released National Quality Forum Roadmap for Promoting Health Equity and Eliminating Disparities which includes several helpful recommendations for how to incentivize the reduction of health disparities and achievement of health equity.3 The RWJF-funded National Academy of Medicine report, Communities in Action, released in January of this year is another valuable resource.4
As part of this effort, it is important for the Innovation Center to address special needs in the context of the health care safety net, which includes Federally Qualified Health Centers, community behavioral health organizations, Critical Access Hospitals, and Tribal Health Centers, among others. We encourage the Innovation Center to increase its initiatives to focus on the safety net because we believe that it is critically important not to leave the population served by these organizations behind in efforts to improve quality and value of care. New payment models often carry high financial, technological, and personnel needs that can be prohibitively expensive and risky investments for providers operating on extremely limited margins and while caring for especially vulnerable populations. Safety net organizations tend to have more difficulty meeting the requirements of broadly-designed payment and care delivery models compared to non-safety net organizations. Safety net organizations will benefit most from advanced payment models designed with them in mind.
RWJF appreciates that the Innovation Center is already considering the principle of patient-centered care which provides an opportunity to drive meaningful change so that people are getting the care that meets their goals, needs, and preferences. We encourage the Innovation Center to set expectations for patient-centeredness that emphasize opportunities to empower patients as consumers and ensure that health care systems are designed around the patients they are intended to serve. Specifically, with respect to metrics by which to gauge the success of new innovations, we urge the agency to include the principles of patient-centered measurement that American Institutes for Research developed with RWJF funding. These principles emphasize that measurements be patient-driven, holistic, transparent, comprehensive and timely, and co-created with patients.5
RWJF believes it is also critically important that people are given the information they need to make decisions that are right for them. When it comes to helping patients make health care decisions, people want information they can understand and that is easily accessible to them, particularly about cost.6,7 As the Innovation Center moves in the direction of providing consumers with more information, however, we want to emphasize that trust can be a major issue for many consumers—we have found in our research that people don’t necessarily trust the information they are given and they can feel alienated from the health care system based on previous negative experiences with it which can impact their care and health outcomes. This is especially true for lower-income, sicker patients, many of whom feel disrespected by providers. On average, patients who feel disrespected by providers are twice as likely to not follow their medication protocols. It is important to address these trust issues as part of any patient-centered care agenda.8
In addition, we encourage the Innovation Center to recognize that it can be challenging for people to feel ownership of their health and health care, even with full information, if they do not feel the support and partnership of their clinical care team. Especially when it comes to cost and appropriateness, patients rely on clinicians for information and support. We have worked with a range of partners, like Choosing Wisely, to make sure that providers are engaging patients in decision-making about what the right care is for individuals based on their specific needs.9 Shared decision-making is critically important and would be an extremely helpful tool for the Innovation Center to include in its models being tested.10
As the Innovation Center explores work with state-based models, we note that states can play an important role in ensuring that people are receiving patient-centered care by creating the conditions for greater transparency so that people have the information they need by requiring that health plans engage consumers in their care and by requiring reporting on measures that matter to patients, caregivers, and families.
We know that access to high-quality health care is critical to health outcomes but many patients’ health issues are complicated by underlying social needs that expand outside the clinical setting. In order to truly improve health outcomes and expand the value of health care dollars, it is important that social needs are addressed as well.11,12 For that reason, RWJF believes it is critically important that, as new payment and delivery system models are developed and tested, they include assessment, planning and payment that address the range of patients’ needs, whether they be physical health, oral health, social/emotional health, and social factors.
In order to truly improve health outcomes and expand the value of health care dollars, it is important that issues like nutrition, education, housing, employment, and transportation, among others are addressed as well.
At RWJF, we are working on the capabilities and incentive structures health and health care systems need to provide people with complete, appropriate care. These include integrated behavioral and physical health care services, trauma informed care that addresses patients’ traumatic experiences and their associated health effects; and data systems that connect across sectors using innovative technologies to provide a full picture of a person’s physical and social health to their providers.13,14,15 We would also urge CMS to continue to advance the work being done to care for the segment of the population that has especially high medical, psychological and social needs to ensure coordinated, effective, and comprehensive care.16,17 This includes team-based, data-driven, holistic, and coordinated care with payment systems and incentives that support such approaches.
Finally, we urge CMS to consider innovations needed especially for children and families, such as multi-generation approaches, efforts to connect data across early childhood-serving systems, and provide evidence-based care to support physical, social, behavioral and cognitive development, in addition to aligning metrics across systems to promote coordinated care and address the needs of the entire family. If children, especially the most vulnerable ones, are not provided the supports they need early, they can become adults with more complex medical and social needs.18 States can do a lot to promote greater holistic and integrated care in setting Medicaid payments and measuring quality.19
Value of Collaboration
RWJF encourages CMS to promote alignment across sectors whenever possible. For example, this could include governance requirements, shared measures, shared data, connected information systems, building on lessons in Accountable Communities for Health, and shared funding approaches (e.g., global budgets, braided and blended funding arrangements). This could also include incentivizing cross agency collaboration.20 All payer models offer promise, because the more Medicare and Medicaid payment models can align, the more potential there is for both reductions in administrative burden for providers and true delivery system reform that improves care delivery, patient outcomes, and high value spending. This also means getting state-level engagement in new Medicare and Medicaid models to foster a true partnership between states and the federal government to move health and health care transformation forward. We are currently exploring different payment models that incentivize collaborative efforts at the community level to address population health.21 If CMS is interested, we would be happy to share our findings as they become available.
Critical Importance of Research, Evaluation and Learning
The Innovation Center principles recognize the importance of research and evaluation. We want to emphasize the value of true learning from the new models being developed across CMS. It is critically important to not only look at outcomes overall, but to understand outcomes across programs and sub-populations, and evaluate implementation. Importantly, we also ask CMS to engage directly with patients themselves about the impacts or potential impacts of different programs.
As an organization that is rooted in evidence, learning also is critical to our work. We commend the Innovation Center for its learning activities, especially through State Innovation Models and the Innovation Accelerator Program. We encourage CMS to continue to think of ways for different stakeholders—providers, payers, and states—to learn from each other by sharing best practices and challenges and also by sharing data in order to encourage additional research and learning. Again, states can play an important role in spreading learning as they establish infrastructure to learn from their policymaking decisions and innovations and move toward evidence based policymaking.22,23,24 We are especially interested in learning from state innovations through different waiver opportunities and accompanying evaluations.
In conclusion, we appreciate the opportunity to comment on the new directions the Innovation Center is considering. Innovation and learning are significant to our work at RWJF and we are happy to continue conversations with CMS about what we are doing to help improve the health and well-being of individuals, families, communities, and the nation.
About the Robert Wood Johnson Foundation
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.
1 Robert Wood Johnson Foundation. Achieving Health Equity. www.rwjf.org/en/library/features/achieving-health-equity.html
2 Learned through our work with Finding Answers: Solving Disparities through Payment and Delivery System Reform at University of Chicago. www.solvingdisparities.org/
3 Chin, MD, M. (2017) The NQF Roadmap for Promoting Health Equity and Eliminating Disparities: Diverse Voices Produced Strong Recommendations. Finding Answers. Solving Disparities through Payment and Delivery System Reform. www.solvingdisparities.org/blog/nqf-roadmap-promoting-health-equity-and-eliminating-disparities-diverse-voices-produced-strong
4 National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, D.C.: The National Academies Press. doi.org/10.17226/24624.
5 Developing Principles of Patient-Centered Measurement. Center for Patient & Consumer Engagement. aircpce.org/projects/developing-principles-patient-centered-measurement
6 Right Place, Right Time. Improving Access to Health Care Information for Vulnerable Patients. Consumer Perspectives Executive Summary. altarum.org/sites/default/files/uploaded-publication-files/RPRT%20Executive-Summary.pdf
7 Still Searching: How People Use Health Care Price Information in the United States, New York State, Florida, Texas and New Hampshire A report from Public Agenda by David Schleifer, Rebecca Silliman and Chloe Rinehart www.publicagenda.org/pages/still-searching
8 Oliver Wyman Insights. Healthcare is only as high value as it is accessible. www.oliverwyman.com/our-expertise/insights/2016/jun/oliver-wyman-_-altarum-institute-study.html
9 Choosing Wisely. A Special Report on the First Five Years. www.choosingwisely.org/wp-content/uploads/2017/10/Choosing-Wisely-at-Five.pdf
10 Millenson, M, Berenson, R. Shared Decisions in Cancer Care: Is Medicare Providing a Model? Urban Institute. April 2017. www.urban.org/research/publication/shared-decisions-cancer-care-medicare-providing-model
11 Centers for Disease Control and Preventions. Social Determinants of Health Know What Affects Health. www.cdc.gov/socialdeterminants/
12 Robert wood Johnson Foundation. Strengthening Integration of Health Services and Systems.
13 Menschner, C, Maul A. Center for Health Care Strategies. Key Ingredients for Successful Trauma-Informed Care Implementation. April 2016. www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/
14 Eugene S. Farley Health Policy Center. Creating a Culture of Whole Health. Recommendations for Integrating Behavioral Health and Primary Care. February 2016. farleyhealthpolicycenter.org/wp-content/uploads/2016/02/Culture-of-Whole-Health-Full-report.pdf
15 Data Across Sectors for Health dashconnect.org/
16 Center for Health Care Strategies. Transforming Complex Care. www.chcs.org/project/transforming-complex-care/
17 Camden Coalition of Healthcare Providers. National Center for Complex Health and Social Needs www.camdenhealth.org/national-center/
18 Build Initiative. www.buildinitiative.org/
19 Howard, H. State Health Reform Assistance Network. How States Can Integrate Social Determinants of Health (SDOH) into Payment and Quality Improvement Policies. July 2017. www.statenetwork.org/how-states-can-integrate-social-determinants-of-health-sdoh-into-payment-and-quality-improvement-policies/
20 Howard, H. State Health Reform Assistance Network. New Brief Features Opportunities to Address Population Health Goals through Jointly Employed Measurement and Accountability Tools. January 2017. www.statenetwork.org/new-brief-features-opportunities-to-address-population-health-goals-through-jointly-employed-measurement-and-accountability-tools/
21 AcademyHealth. Payment Reform for Population Health. www.academyhealth.org/about/programs/payment-reform-population-health
22 Pew-MacArthur Results First Initiative. www.pewtrusts.org/en/projects/pew-macarthur-results-first-initiative
23 Washington State Institute for Public Policy. www.wsipp.wa.gov/
24 Center for Evidence-Based Policy. centerforevidencebasedpolicy.org/