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Medicaid will be an increasing focus of alternative payment models (APMs) from the Center for Medicare & Medicaid Innovation (CMMI), Ellen Lukens, MPH, said Wednesday at the annual Population Health Colloquium hosted by Thomas Jefferson University.

"Models have been predominantly Medicare-oriented, and have disproportionately served white beneficiaries," said Lukens, who is policy and programs group director at CMMI, in the Centers for Medicare & Medicaid Services (CMS). "Few of our models have focused on Medicaid beneficiaries, and few of our models have included robust participation from safety-net providers ... We are really invested in including some of these changes so that Medicaid beneficiaries can benefit from some of the innovations that we're testing with Medicare."

Health equity will be another focus, Lukens said, "and it's really going to be a focus on including equity in every aspect of the model, from model conceptualization to model application to thinking about what providers might be interested in our models ... We think by really centering equity in every part of model decision-making, [it] will really expand the scope and range of our participation."

Paring down the number of models is also a priority, said Lukens, echoing similar comments made last week by her boss, CMMI Director Elizabeth Fowler, PhD. "I think the feeling is that we may have offered too many models, which has created complexity for the center, and for participants," said Lukens. "Specifically, there have been concerns about overlap where specific providers in a market will actually be treating the same beneficiary, and in that case there are often questions about, 'Well, who gets to share in the savings? How is the savings calculated when we're both involved in the care?' We recognize that that is a question that has plagued many of our models. And we are also thinking about that as we move forward, and thinking about, do we want to have so many models?"

"So we are now focused on launching fewer models that are more harmonized," said Lukens. "One thing we've heard from the provider community is that we need a harmonized set of models, and that is something that we are actively engaged in."

Setting better financial benchmarks is another goal for CMMI, Lukens said. "There have historically been some challenges in setting financial benchmarks, and in some cases it has undermined the model's effectiveness in terms of the evaluation and how the evaluation reports model savings ... We have to get better at that, and I think we have over the past couple years."

Some CMMI models have had remarkable success, she said, listing six in particular that have met requirements for national expansion:

• ACO [accountable care organization] Investment Model
• Pioneer ACO
• Y-USA Diabetes Prevention Program
• Maryland All-Payer Model
• Repetitive Scheduled Non-Emergency Ambulance Transport Model
• Home Health Value-Based Payment Model

While CMMI's earlier models had little financial risk for participants, "our newer models include higher standards and quality reporting, but also more opportunities for shared savings, and more integration of clinical treatment and social services," said Lukens. "They also have more financial risks. So as you see the innovation center move toward fewer models ... and a more beneficiary focus, you'll see some of these changes accelerate over the next few years as we really try to think through how we do this better."

During a separate conference session, Ezekiel Emanuel, MD, PhD, co-director of the Health Transformation Institute at the University of Pennsylvania, offered several recommendations for designing APMs. First, he suggested, the country needs to focus on public/private partnerships. "We need to get everyone involved with alternative payment models -- Medicaid, TRICARE, [Affordable Care Act] exchange plans, and commercial plans, as well as Medicare," he said. "Medicare is important; in some ways it's the fundamental pillar, but it is not alone. We really need to try to get as much revenue going in the same direction as possible, and I think these public/private partnerships is an ideal way to do it."

The government also should require insurance plans sold on Affordable Care Act exchanges to commit to APM adoption, said Emanuel, who was a health policy advisor in the Office of Management and Budget under President Obama. "That will be really important. While they're not huge -- 12 million people -- they do represent important facets of connecting with private partnerships."

In addition, APMs should be mandatory, he said. "We've had a lot of experimentation with voluntary programs," Emanuel said. "We've learned a lesson that the practices that come in, they know that they're going to succeed. We've allowed too many to game the system, and we need to curtail the ability of providers to opt out of value-based payment altogether, and to get all of them to experience value-based payment in these alternative payment models, and to make the necessary practice changes to succeed at them."

In America, mandatory APMs "are really the alternative to having a fee-for-service system within a budget, which is done typically in Europe, in Taiwan, and in other countries," he added. "So, for example, in Germany, if doctors submit too much utilization and bill too high, they only get 90 cents on the dollar or 87 cents on the dollar, because that's the budget ... We failed at that in the Medicare program. So mandatory APMs are really the alternative to keep costs within a constraint."

Realignment of economic incentives also is needed, according to Emanuel. "The amount of revenue focused on the incentives needs to be 20% or more," he said. "You have to allow physicians to be hugely successful if they do the right things." That means they'll also need timely information so incentives can be properly allocated; "they need to know who's being attributed to them, they need to know how they're performing. It's really hard to transform your practices and to understand what you're doing right or wrong" if you don't have up-to-date information, he said.

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