Holding the health care system accountable for the cost, quality, and equity of care is an important way to further those goals, while encouraging innovation among providers, plans, and localities. For more than a decade, the Center for Medicare and Medicaid Innovation (CMMI) — part of the Centers for Medicare and Medicaid Services — has tested approaches to holding various actors (e.g., providers, health plans, health care delivery systems) accountable. CMMI has had some success, but its methods have too often been diffuse, misaligned, and incomplete.

CMMI leadership has signaled plans to revisit its models, and to reflect on evidence from more than a decade of innovation to identify what to discontinue, accelerate, or initiate. CMMI can address past challenges in its approaches and reimagine a future of greater shared accountability among stakeholders to improve quality, lower health care costs, and increase equity.

Framework for Accountability

There are multiple levers CMMI can pull to hold different actors accountable for outcomes in health care. While value-based payment is a key lever, and gets the most attention, it is not sufficient on its own. An aligned array of financial and nonfinancial incentives that touch multiple actors can promote joint accountability, resulting in better overall health system performance. Each of these levers can be applied on a voluntary or mandatory basis; some mandatory approaches may require legislation.

Promising Areas for Future Innovation

There are several evidence-based, promising approaches for holding health care accountable that CMMI should consider:

  1. Physician-led ACOs. Physician-led accountable care organizations (ACOs) have been one of the most successful payment reforms tested in the past decade, although gains have often been modest. Physician-led ACOs have an advantage over those led by hospitals: physicians, unlike hospitals, do not have incentives to keep beds full and are thus more open to less-costly approaches to meeting patients’ needs. CMMI can build on progress and accelerate adoption of physician-led ACOs by combining levers for accountability and perhaps making participation mandatory. CMMI could offer more powerful financial incentives, apply prospective payments for defined populations to increase predictability for providers, incorporate accountability for equity, and require community representation on governing boards as a condition of participation. Further, ACO models could be supplemented with evidence-based bundled payment models, which engage procedure-oriented specialties and are easier to implement than comprehensive population-based models in organized delivery systems. When implemented with ACOs, bundles are more likely to be coordinated with other care and incentives to increase volume are reduced. ACOs also could include full or partial primary care capitation to promote coordinated, population-based care at the front lines.
  2. Geographic models. Geographic-based models of accountability have shown promising results. CMMI could consider expanding these approaches, applying different levers to ensure accountability for total cost, quality, and equity of care for defined populations in specific jurisdictions. As with ACOs, the models could incorporate capitation or partial capitation of primary care providers who are best positioned to provide cost-effective and critical services like care coordination and prevention.
  3. Home-based care. Comprehensive home-based care models, particularly those serving the homebound or people with complex health and social needs, have created meaningful improvements for patients, along with lower Medicare costs. CMMI could expand successful programs like Independence at Home, increase accountability among home care agencies, and encourage the provision of home-based care in other accountability models. Health plans (either Medicare Advantage or Medicaid managed care) or ACOs, together with the provider teams delivering comprehensive home-based care, could be jointly accountable for cost, equity, and quality of care.
  4. Medicare Advantage plans. CMMI may consider using the Medicare Advantage (MA) program as a key target for expanded accountability. One drawback is that some MA plans compensate providers on a traditional fee-for-service basis, thus failing to incentivize them to devise more cost-effective treatment plans. CMMI could test requirements for MA plans to delegate risk and resource-allocation decisions to clinicians as a way to promote joint responsibility for cost, equity, and quality of care. CMMI could then consider reviewing and improving the star rating system to ensure higher ratings are associated with better care and greater equity.

In each of these areas, CMMI can consider making models mandatory, with appropriate controls and financial or technical support where needed, and work to include and align payment arrangements across public and private payers. To reduce administrative burden, participating clinicians could face fewer reporting requirements and requirements for prior authorization and utilization review. As we’ve learned from other models, it’s important to increase auditing of coding practices to ensure risk adjustment is valid and appropriate, that it incorporates socioeconomic variables, and that providers do not engage in cherry-picking.

Accountability for Racial Equity

The Center for Medicare and Medicaid Innovation’s models to date have not routinely or sufficiently considered impact on racial equity. Going forward, CMMI should prioritize equity of care by considering potential impacts on equity in model design and development; developing feasible, consensus-driven metrics on equity of care provided; and holding health systems, providers, and payers accountable for measuring and increasing equity of services received by patients.

CMMI can use various mechanisms to advance equity, including directly paying for performance on equity of outcomes, requiring the collection and public reporting of data by race/ethnicity, and requiring participating entities to create plans to reduce documented inequities. Further, CMMI could revisit its risk-adjustment methodologies to ensure they are not disadvantaging entities serving populations of color, low-income patients, or people with complex health and social needs.

Ensuring accountability is currently the central challenge of delivery system reform. Value-based payment is a very popular approach, but it should be part of a comprehensive, multifaceted strategy that brings together a variety of mechanisms. CMMI has the opportunity to build on past experience and demonstrate how to take health care delivery to a new level.