CMS Announces AHEAD Model to Promote Health Equity and Value-Based Payments
AHEAD Model has the potential to revolutionize the way we approach healthcare, moving towards a more integrated, efficient, and equitable system.
THE VBP Blog
September 28, 2023 – Ensuring health equity and access to quality care for all is a central goal for the healthcare industry. Yet, disparities continue to exist. Recognizing the need to bridge these gaps, CMS recently introduced The States Advancing All-Payer Health Equity Approaches and Development Model (AHEAD Model).
This innovative model promises not just to advance healthcare, but to redesign the frameworks to focus more holistically on equity with a focus on primary care and community-based services. What is the AHEAD Model and how does it work? Keep reading to explore the nuances of the AHEAD Model and its potential to transform the healthcare landscape.
What is the AHEAD Model?
The AHEAD Model is the CMS response to the long-standing health disparities that exist across the country. At its core, it is designed to empower states to foster health equity across all payers, blending private and public sector efforts to reduce systemic health disparities. According to CMS, the model is adaptable and gives states the flexibility to design and implement equity interventions that resonate with their unique healthcare challenges.
The AHEAD Model is a state total cost of care (TCOC) model that intends to drive state and regional health care transformation and multi-payer alignment, with the goal of improving the total health of a state population and lowering costs. Under a TCOC model, participating states assume responsibility for managing health care quality and costs across all payers. This includes Medicare, Medicaid, and private coverage. States also assume responsibility for ensuring health providers in their state deliver high-quality care, improve population health, offer greater care coordination, and advance health equity by supporting underserved patients.
To revamp the overall cost care structure across selected states, CMS will collaborate closely with involved parties to determine a Medicare total cost care growth target. Each participating state will also define its own all-payer cost growth benchmarks. States will have all-payer and Medicare primary care investment targets. In addition, states have the flexibility to launch hospital global budgets and can tailor their global budget strategies or use the CMS-established methodology with specific parameters. Both hospital global budgets and primary care investments will incorporate social risk assessments and reward hospitals showing marked improvements in care disparity measures.
To implement these changes, CMS will not only collaborate with state governments, but also provide monetary incentives. This is a voluntary model and up to 8 states can receive up to $12 million. These payments will be distributed as an initial award followed by subsequent non-competitive annual rewards.
CMS Administrator Chiquita Brooks-LaSure touted the new Model, stating, “In our current health care system, fragmented care contributes to persistent, widening health disparities in underserved populations. The AHEAD Model is a critical step towards addressing disparities in both health care and health equity while improving overall population health.”
The AHEAD Model is slated to run for 11 years. CMS plans to announce the first of its two funding opportunities in fall 2023 and spring 2024. The entire model will wrap up by December 2034. However, exact commencement and conclusion dates for participants hinge on their selected cohort, which is based on their readiness level.
Looking at the monetary and timeframe commitment, it is important to note that the AHEAD Model is not just a fleeting initiative. It’s a calculated, long-term commitment by CMS and participating states to bolster health equity. And as it unfolds, it holds the potential to create lasting changes in the U.S. healthcare system.
Core Elements of the AHEAD Model
As healthcare systems worldwide evolve, the AHEAD Model is a commitment to innovation and health equity. However, like most revolutionary ideas, the AHEAD Model didn’t emerge from thin air. Its roots can be traced back to three previously launched programs: the Maryland Total Cost of Care Model, the Vermont All Payer ACO Model, and the Pennsylvania Rural Health Model.
The AHEAD Model is, in many ways, an evolution and combination of these prior programs and the next iteration of the CMS Innovation Center’s multi-payer total cost of care models. Core elements of this innovative model include an emphasis on primary care, all-payer models, community health initiatives, and health equity.
Primary Care: One of the core tenets of the AHEAD Model is its emphasis on strengthening primary care. Historically, CMS has been a strong supporter of primary care, given its critical role in patient health and overall system efficiency. Studies have shown that patients who do not see a primary care provider regularly are less likely to get regular health screenings, monitoring for emerging health issues, and other preventive health care. This can lead to worsening health, which causes them to seek care in higher cost of care settings like hospitals, urgent care, or specialty care.
Prior CMS initiatives like the Comprehensive Primary Care Plus (CPC+) and Primary Care First models have stressed the importance of primary care transformation. These programs have aimed to enhance care delivery, ensure better patient outcomes, and promote value-based care. The AHEAD Model draws from these initiatives, expanding their scope and impact across states. It does this through model sets three key pillars for primary care transformation: the integration of behavioral health, addressing health-related societal needs, and ensuring care management alongside specialty coordination.
All-Payer Models: The AHEAD Model’s approach to total cost of care is not entirely novel. CMS’s past endeavors, such as the Maryland and Vermont All-Payer Models, have sought to control cost growth while ensuring high-quality care. These models attempted to align hospital incentives across all payers, fostering a collaborative rather than competitive environment in healthcare. All-payer models include not just federal payers like Medicare and Medicaid, but private payers as well. The assumption is that the shift to value-based care and population health management requires sustained focus, and this is simply not possible with some payers still in the fee-for-service model. While shifting to an all-payer model is important, only time will tell if CMAS and states can get private payers buy-in.
Community Health Initiatives: The focus on community resource alignment and health-related social needs in the AHEAD Model resonates with CMS’s longstanding commitment to community health. Earlier models have acknowledged how social determinants of health influence health outcomes, and we’ve written about it in past blogs as well. The AHEAD Model aims to increase screening and referrals to community resources by primary care providers. By addressing SDOH like housing, transportation, and diet, the goal is to improve health outcomes in addition to lowering healthcare costs.
Health Equity: The other main focus of the AHEAD Model is health equity and reducing disparities by supporting underserved populations. In fact, states that choose to apply must have a detailed plan for how they will measure and promote health equity. States will also be required to implement and participate in their statewide health equity plan, as well as a statewide, cross-sector model. Hospitals also must formulate a health equity plan that coincides with the state’s goals. It’s also interesting to note that while hospitals and primary care practices will be the epicenters of intervention, the focus on health equity and community health initiatives can open the door for home health and home care companies to create opportunities.
While the AHEAD Model is ambitious in its scope and objectives, understanding its roots provides a clearer picture of its potential trajectory. By building on the successes and lessons of past programs, CMS is aiming for a more integrated, equitable, and effective healthcare system for all.
Challenges to Implementing the AHEAD Model
While the AHEAD Model has noble and ambitious goals, there are some challenges to successful implementation that need to be considered.
Stakeholder Buy-In: Achieving consensus from all stakeholders, including private payers, hospitals, and primary care providers, is crucial. Past models faced challenges with comprehensive buy-in. One example of this is Vermont’s model. While touted as an all-payer model, larger private payers United HealthCare and CIGNA never joined, and Blue Cross Blue Shield recently dropped out. The AHEAD Model will need to ensure its attractive enough for widespread adoption if it is to become a true all-payer model and achieve the transformation it strives for.
Data Availability and Analysis: Adequate, reliable data is fundamental for any model’s success. Pennsylvania’s Rural Health Model, for instance, has limited empirical data available on performance. The AHEAD Model will need consistent, transparent data reporting mechanisms to gauge its effectiveness and adjust accordingly. There are some mechanisms in place to obtain this data though, as participating hospitals and primary care practices will enhance demographic data collection and health equity benchmarks and monitoring are included in the model as well.
Financial Challenges: The fiscal structures, such as the significant Medicare investment seen in the Maryland Model, pose challenges for widespread implementation. While this model involves all payers in Maryland, CMS cannot afford the investments necessary to bring federal payments to parity with private payers. Achieving a balance that’s attractive for both insurers and providers, while also being sustainable, will be a complex task and require careful consideration.
Scalability: Prior models might be working well on a smaller scale, but replicating such success across multiple states, each with its unique healthcare landscape, will be challenging. Ensuring the model is adaptable and resilient is crucial for its widespread success. It’s also worth noting that the United States is facing a primary care shortage and by 2033, the shortage is expected to range from 21,000 to 55,000. That could also create an obstacle to widespread implementation, although there is the option to connect practices to community-based resources that can leverage more home- and community-based care.
The AHEAD Model aims to consolidate lessons learned from various state-specific models into a comprehensive, nationwide strategy that enhances health outcomes and reduces total cost of care. While it builds on the successes of its predecessors, it also faces the challenge of overcoming their limitations and navigating new territory. Stakeholder buy-in, financial considerations, and scalability are among the key challenges that lie ahead. Yet, if addressed effectively, the AHEAD Model has the potential to revolutionize the way we approach healthcare, moving towards a more integrated, efficient, and equitable system. The model has lofty and admirable goals of improving access to and quality of primary care, addressing social determinants of health through referrals to community resources, and advancing health equity to remove disparities. These model components can enhance coordinated, whole-person primary care that will benefit consumers and improve health outcomes in participating states. It just remains to be seen how well the model can be implemented on a large scale and whether CMS will get the results it is looking for.
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.