It’s been a busy year for healthcare transformation, with CMS introducing two nationwide payment models to advance reforms that we predicted nearly ten years ago in our Healthytown work. The Making Care Primary model is focused on primary care, and it has enormous potential for physician practices that need additional support in moving to value-based care.
Even more ambitious is the AHEAD model (or, in its clunkier, non-acronym form, All-Payer Health Equity Approaches and Development). This is a total cost of care (TCOC) model, meaning it tries to account for all the healthcare costs of a defined population, both inside and outside the hospital.
CMS says AHEAD is designed to build on the success of innovative, state-based models in Maryland, Pennsylvania, and Vermont, but the new effort goes further than anything those states have attempted. With this model, CMS is trying to combine four major reforms that have never been implemented all together:
Personally, I hope CMS finds success with both of the new models unveiled in 2023 because the trajectory of the US healthcare system remains unsustainable, even after decades of tinkering at the margins. We’ve argued for years that payment models need to catch up with trends in demographics, technology, and consumerism.
Much of that change is reflected in Maryland’s long-running Medicare waiver, which is the primary inspiration for the AHEAD model. Across Maryland, we’ve worked extensively with hospitals, local health departments, and state agencies, giving us unique insight into the most successful TCOC experiment in America.
For instance, in 2021 the Maryland Health Services Cost Review Commission (HSCRC) engaged Ascendient to create a strategic plan that would “articulate the ideal future position for the HSCRC and the Maryland Model for the next ten years.” Because Maryland state government is admirably transparent, much of that work is publicly available online (pages 29-43).
In addition to data analysis and a national trend scan, we polled and interviewed dozens of stakeholders representing health systems, provider groups, payers, state associations, government agencies, and more. We wanted to know two things: 1) Did stakeholders believe the Maryland model was working; and 2) What changes would they like to see in the model going forward?
Several of our findings may be helpful for other states weighing the option to join AHEAD:
All of this is relevant because Maryland’s healthcare stakeholders probably know better than anyone what it takes to have a successful TCOC program. So far, CMS has offered only a high-level view of the AHEAD model, but once full guidelines are released, we recommend that states pay careful attention to details like who sets targets, how much flexibility is offered, and how the program incorporates non-hospital providers. Those details may speak volumes about what CMS has learned from the Maryland model.
I can’t begin to guess how many states will volunteer for the AHEAD model, though Vermont already has signaled its intention. CMS says only eight states will be chosen, but applications could lag that target – or exceed all expectations. For states that are seriously considering the model, my advice would be to take a deep dive into the experience in Maryland. This Higher Thinking paper that we recently republished is a great place to start. For additional questions, feel free to contact us.
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