Featured topic and speakers
In this episode of Moving Medicine, AMA CEO John Whyte, MD, MPH, talks with Abe Sutton, JD, director for the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator for CMS, about the potential benefits and challenges of a new outcome-aligned payment model called ACCESS, and what it means for physicians and patients. Learn more at CMS.gov.
Speakers
- John Whyte, MD, MPH, CEO and executive vice president, American Medical Association
- Abe Sutton, JD, director, Center for Medicare and Medicaid Innovation (CMMI); deputy administrator, Centers for Medicare & Medicaid Services (CMS)
Transcript
Sutton: What this model is focused on is how we can leverage new approaches to care for patients and reward the delivery of care that drives better outcomes.
Dr. Whyte: Welcome to Moving Medicine, a podcast from the American Medical Association, where we explore the policies, innovations and opportunities transforming health care today. I'm Dr. John Whyte, the CEO of the AMA. We have a special guest, an exciting discussion today with one of the people truly driving meaningful change in our health care system. Abe Sutton is the director of the Center for Medicare and Medicaid Innovation, CMMI, and deputy administrator for CMS.
He and his team develop and test health care payment and service delivery models to improve patient care, lower costs and promote patient-centered practices. He's here to talk about a brand-new model and what it means for patients and physicians. Abe, welcome to the podcast.
Sutton: Thank you for having me on. It's a privilege to be here, Dr. Whyte.
Dr. Whyte: Well, Abe, you have this new model called ACCESS. And I wanted to hear more details about how it's going to address chronic conditions.
Sutton: Well, ACCESS is all about advancing chronic care with effective, scalable solutions. What this model is focused on is how we can leverage new approaches to care for patients and reward the delivery of care that drives better outcomes. And so, ACCESS is about moving beyond a system where we try to define—How much should a technology be paid for? What should we reimburse for a thing?—and instead move to a system where we say, here are the outcomes that matter for a grouping of chronic diseases and focus on the management of those conditions.
Let's manage them. Let's drive better outcomes compared to where a patient was. And if you do, you'll be rewarded with a monthly payment that is designed to help fund the activity that you're doing.
Dr. Whyte: OK. So let's talk about that. It's really this outcome-based approach for payments. But we've had that for years. How is this model any different? What should a listener know?
Sutton: So we haven't tried it in this way. We've tried outcome-based payments for specific conditions or bundles that are really, really technical. We've had approaches that look at the total cost of care and think about the accountable care organizations. What this is about is groupings of major chronic conditions defining very specific clinical outcomes that we're going to track and says, OK. Manage that. Use whatever approaches you need to use. Leverage different technologies that are out there. We're not specifically going through and saying, we'll pay for this one or we'll pay for that one.
And let you choose to bundle them together—say, this is the care pathway and regimen that I want to use—without signing up for global risk on the entire care the patient represents.
Dr. Whyte: But on those conditions—
Sutton: But on those conditions—
Dr. Whyte: —and the outcomes.
Sutton: —and the outcomes, not the total cost profile. And so, between this early cardio-kidney metabolic health, the later cardio-kidney metabolic health, the musculoskeletal tract and then the behavioral track, we're covering around two-thirds of Medicare beneficiaries being eligible to receive care from a physician or grouping of physicians in an organization that are looking to help manage these conditions.
Dr. Whyte: And how do you choose these conditions? Is it because you felt patients were not having good outcomes? They weren't at goal, say, for diabetes? There's lots of things that you could have chosen. Why these four tracks?
Sutton: So, Secretary Kennedy has made a clear call to need to focus on chronic disease management. We've seen some promising signs in looking at care models that are used in the commercial space today that approach a different aspect of these. And we see a large issue with many people impacted within each of these tracks—so the combination of the promise of what can be achieved and the stakes of the problem that we see in line with the secretary's mission to address this issue.
Dr. Whyte: Are you determining the outcomes in each of these? And how do you know you picked the right outcomes? Because physicians will always say that, well, I would have chosen some different measure. This is a conversation we have in value-based care, that they're not the right outcome. So how did you determine them? And how do you know they're the right ones?
Sutton: So there are things that we could collect in the data. We don't want it to be things that are easily gameable. So if you think about someone's A1C levels—If you see improvement on A1C for a patient who has not been tracking well, that matters. That can make a difference. The exact amount of scale of improvement you need to see, well, that will differ by patient. But showing improvement matters directionally. For a behavioral health patient, their reported outcomes of what they're experiencing—that matters. Are they experiencing symptoms of depression?
What we want to do is get at things that we could easily track data on and also drive enough of a difference where it's meaningful, where we can meet the actuarial standard to be able to certify, yes, this works. In designing this, we have a whole team that we work with, with actuaries, with clinicians who have expertise in these areas. And we also went out and spoke to different players who are helping approach the management of these areas to see what would be meaningful, what would move the needle enough that this could become a real part of the Medicare program going forward.
Dr. Whyte: But fundamentally, what are the needs and the challenges that the model's trying to address? And why this model to address it? Is it because we're having poor control of diabetes, we're having increase in metabolic dysfunction? What are you trying to address?
Sutton: We're experiencing a rising chronic disease burden in this country. We want to halt and reverse that. And we have the potential to do so. We're at a moment where there's transformative potential from new technologies that can be leveraged to improve access for patients, to help them manage their chronic conditions. So let me think of an example for this.
Dr. Whyte: Transformative.
Sutton: For patients. So, if I think about a cardiologist-led organization that's trying to help somebody manage a medical condition—and so you could have a connected blood pressure cuff. And you could see how patients are doing. And then you could remotely help them titrate their medications. You could also have a sort of nutrition coaching app to help them help get the right foods that they need.
Because it could take a picture of the foods that they're eating. And it could tell them what's healthy and what's not. And it could show how that is impacting their numbers because the input from the app is being combined with the input from the cuff. OK. That's pretty cool, that you could set up a system and automate it for the management of a patient's condition. Now let's hook that up and give data from that back to the patient's cardiologist—or, if they're not engaged with the cardiologist, with their primary care physicians—and then have that data available when they come in for their regular appointment. Or if something is really serious, have it flagged that maybe they need to come in.
And so, this system of complementing the relationship that a patient has with their doctor, with a physician-led approach to leverage new technologies in different forms that we're not exactly saying have to be this way or that way, can lead to better outcomes for patients.
Dr. Whyte: I love the physician-led approach because that is something that needs to be at the center. But with this technology, in terms of the pictures, that already exists. In terms of the blood pressure, that's been a model that's been used before, particularly with patients with difficult hypertension. We see it with congestive heart failure. Now, will these technologies and tools—they won't technically be reimbursed or paid for. Is that correct? But if they improve outcomes, then one will receive a reward, as you say, in terms of incentive?
Sutton: So what we're setting up is a monthly payment for the management of the condition. And that can go to a physician-led organization managing the condition. And that pays for access to these different devices, technologies. And so, rather than say this technology is worth that much and that technology is worth that much and having a system to evaluate that, let's step back from that. Let's get away from bureaucrats in Washington defining what we pay for in health care and instead say, we pay for outcomes.
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And let's give the different organizations the choice of exactly how they're going to achieve those outcomes. And let's take the data on what they achieve and post that on our website of, this organization achieved that outcome. That organization achieved that outcome. And other physicians could go and see—all right, I'm going to send my patients there and not there—because that is the type of management that I want them to have access to.
Dr. Whyte: So we pay for outcomes. But then there's a disincentive as well for poor outcomes. Correct?
Sutton: Well, if we're paying for outcomes, you're not achieving them and you're not being paid. And what we're going to do is raise the standard for different organizations over time of what's required to continue participating in the ACCESS model.
Dr. Whyte: And I think that's an important distinction, that someone is getting more. Someone is not being penalized for it. But to be fair, physicians have not always embraced these types of tools. They may not be as familiar with them. Or there's issues of interoperability, in terms of, how am I going to get that information from the phone into the record so I, as a cardiologist, can make a better decision as to the management of their lipids or the management of their blood pressure? So how do you address that aspect?
Sutton: We're building in requirements for the organizations participating in this model, that they share back that data and have the capability to do it. Because otherwise, they're actually not setting up their patients for optimal success if they're not enabling a care relationship with a physician. I think care is local. Care begins in a community. And care begins with two people sitting down with one another and having a conversation.
Technology can support that. And the idea is that we will require that the data be shared back with the proper entity and custodian to help manage that relationship with the patient.
Dr. Whyte: But you need physicians to participate if you're able to test the model. So I, as a listener, how should my evaluation be, in terms of—hmm, I think I'll participate in this model? What would you advise them?
Sutton: I think about the patients you serve. I think about their experience in managing their chronic diseases. And I think about if you think you can do more for them and deliver better supports for them in that time between visits. If you think that could make a difference for some of your patients, I would go and look up on our website to see what tools are available, who signed up and see if any of them you might work with on your commercial patient population as opposed to your Medicare today. And maybe you want to start working with them for Medicare patients as well.
Dr. Whyte: And it can be a variety of tools. And physicians have to have confidence in it, the fidelity of these tools as well, that they're going to have an impact. But we also have to be very practical for patients. Cost sharing is just a reality for many people. So what's the flexibility that this model allows for cost sharing?
Sutton: So we're allowing the organizations to choose to completely waive cost sharing for beneficiaries. And the reason why that's important is, I didn't want to decide on the front end, inherently, anything in this model should not get any patient contribution because I didn't want to worsen the economics for these participants. But if they choose to waive that—which, given the structure of some of these, which allows for real scale, I think will make sense for them to do—then they'll have an advantage, obviously, in attracting patients in.
And that should matter. They should face market pressure to move in that direction rather than me requiring them to do so. And I think that will help expand access to some of these tools for patients as well.
Dr. Whyte: Now, you're a big fan of technology. That's been your historical expertise. And we recognize that technology changes over time. It should. We should be improved in our use of technology a year or two years from now. Now, this model, it's national in scope. Sometimes models are regional. But this is national. And it's a decade, in terms of how long it's going to last. So how are you going to ensure, given how tech is an important component of this, that the model evolves?
Sutton: One nice thing here is, we're not paying for technology. We want to see technology used in the health care system to drive better outcomes in a deflationary manner, one where we're not paying more and more each year for new things, but instead saying, we pay for achievement of outcomes. Use whatever tools you want to achieve those outcomes. And that's what we care about. We have defined quality goals. And what that sets up is an arms race, where organizations can come in and do research on what the best clinical approach is and then try and scale that throughout the health care system.
Dr. Whyte: So effectiveness is always important of these models. And part of that is also when these are models that you have to have a feedback mechanism, where clinicians, organizations provide some important insights that might lead to change. So how is that set up?
Sutton: So we're going to be getting input in a couple of different ways. One is uptake. To what extent are physicians participating in and working with these different tracks, with companies and organizations that sign up under physician leadership to participate in the model? We need the participants from the organizations, and we need the participation from the physicians for their patients.
We're also going to organize listening sessions, where we get input in these listening sessions or focus groups on what people's experience is like participating in the model. We'll organize some more open versions of that. We'll allow for the sharing of best practices and experience from one part of the country to another between different physicians. And we'll be posting the results that we see for these different organizations participating on our website. And so, that will all be accessible.
We'll look annually at the data that's achieved and publish those reports for the public to see and judge on their own right. And we will make changes if necessary if we see we're not achieving the results that we're hoping to see. So let's say a track is not where it should be. Well, let's recalibrate it. Let's rework it. Let's change—
Dr. Whyte: So there's a commitment—
Sutton: —the metrics.
Dr. Whyte: —to make changes over time based on this feedback.
Sutton: 100%. And that's something that's true of all Innovation Center models. We hope we get it right. We hope we're in a position to certify. But if we're not in a position to certify, then it's our duty to iterate, to try and learn, to try and grow and get better.
Dr. Whyte: And by virtue of it being a model and testing it, there is an acknowledgment, in some ways, that it may not be right and will have to be modified to reach the goals that you want.
Sutton: We spend $1.7 trillion and counting—it grows every year—in Medicare and Medicaid for the care of the patients enrolled in these programs. It's important we spend on research to determine if we are doing this, to determine if there are ways that we could do it better. ACCESS fits into that picture. And then let's see what happens. And if we miscalibrated, we'll improve in the future.
Dr. Whyte: Let's take it from the perspective of a participating organization, physician, patient. The opportunity is, I'm going to get better outcomes and I'm going to be rewarded with higher reimbursement. What's the downside, the challenge?
Sutton: So I think for the organizations that are organizing to participate in this, they really face a high-stakes situation, where if their improvement really drives better outcomes, it's a no-brainer. But if they're not sure and if it doesn't, then they risk not achieving full payment.
Dr. Whyte: What if it's incremental? Most things in medicine are incremental.
Sutton: They'd have to show improvement over time. So it's not each patient, but you have to have a large enough of an impact on a large enough percent of the patients that you serve to get credit and stay in over time. And the other threat is that somebody else does it better. And given that their solution is also scalable, they'll be the one that people refer to when we publicly post this on the website. And so, there is a potential scenario where you come in and you don't actually succeed as a new organization in this structure.
Dr. Whyte: So again, it's a decade. What does success look like for this model in 10 years?
Sutton: When I think about success here, I think about the patients we're trying to impact—people living healthier lives. So success for me in the immediate term is driving impact for those patients. And then in the longer term, it's being able to certify this approach in ACCESS so that this could be available for more patients in the future.
Dr. Whyte: Is it success also, in terms of decreased Medicare spending?
Sutton: Our key metrics, as you are alluding to, are reduced spend and better outcomes. The key metrics that we're looking for here include reductions in spend, bending the cost curve and driving better outcomes for patients. And those are both motivators for us in all of our work.
Dr. Whyte: What about clinicians that say, "Abe, it's hard to do both? It's hard to improve outcomes and reduce spending." Do you agree with that, vehemently disagree with it? Where are we on that? Because this is trying to do both. And it's a noble attempt. So, I'm just going to push you a little on that.
Sutton: So our statute requires us to improve on one without harming the other. So if we do something that massively improves quality and has no impact on costs, that's success. If we do something that reduces costs drastically and has no impact on quality, that is also success. I think it is possible with the same innovation to do both.
I think in this model, we could see improvements on clinical outcomes as the leading indicator of reductions in spend in the future. That would be great. But we can't make a situation worse. We can never harm quality, and we can never increase costs and call what we did a success.
Dr. Whyte: Where can people learn more about the model?
Sutton: So on the CMS website, we have a web page up which has all the information on ACCESS. There's a email address you could reach out to with any questions. There are FAQs. And we'll be putting out more information in the days ahead as there are more questions that we could give answers to. We're also going to be hosting a series of webinars to give information to the public about the model. And so, I'm really excited about this. I hope all of your listeners get excited by this conversation and choose to check it out to learn more. Because I think this can make a real difference for the management of chronic disease in this country.
Dr. Whyte: Abe Sutton, director of the Center for Medicare and Medicaid Innovation and deputy administrator for CMS, thanks for joining me.
Sutton: Thanks for having me on, Dr. Whyte. It was a pleasure.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
