CMS Unveils New AHEAD Model Aimed at State Populations

The Centers for Medicare & Medicaid Services (CMS) has unveiled the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) voluntary model meant to explore a state’s ability to improve to the overall health care management of its population. 

CMS will dole out awards to as many as 8 states, and each chosen state may access funding up to $12 million to support implementation. The model performance period is scheduled to begin in 2026 or 2027, depending on the cohort, and last through 2034, according to a press release.¹

The AHEAD model operates on the idea that states are well-positioned to make a meaningful impact. 

“States have relationships with many of the stakeholders whose perspectives and support will be vital to the success of this model,” Maureen Hennessey, PhD, SVP, director of value transformation at Precision AQ, told First Report Managed Care. 

“States have knowledge of the strengths and limitations of community and statewide health systems, providers, and community-based organizations and their current and historic alliances within their states,” she added. “This knowledge and states’ existing relationships can be leveraged to facilitate system transformation and financial model evolution.” 

Promising Aspects of the AHEAD Model

Dr Hennessey pointed out that issues that misaligned incentives and priorities, lack of transparency, and fragmentation may hamstring the US health care system. However, the “mandatory participation of  hospitals, primary care practices, commercial payers, beneficiary groups, and community-based organizations in a learning system aimed at developing a shared vision for population health and health equity outcomes, supported by tools and technical assistance, could expedite change,” she said. 

Another promising aspect of AHEAD is that it provides opportunities to improve patient access to primary care, said Dr Hennessey. Even though “regular access to a primary care provider is associated with positive health outcomes,” barriers like provider scarcity or distance can prevent regular access for many. She explained that more significant investment in primary care and emphasizing areas such as behavioral health integration and meeting patients’ health-related social needs could help contain costs and benefit patients.  

“Almost everyone with an understanding of the economics of health care agrees that we underfund primary care in this country,” Luis Argueso, partner and co-founder of InHealth Advisors, told First Report Managed Care. “The primary care investment targets in the AHEAD model will encourage additional spending on primary care, which should fund chronic disease management, preventative care, and behavioral health initiatives that will make patients healthier and control health care costs.”

He also highlighted the model’s enhanced primary care payment. Although better-funded primary care ought to lead to better outcomes, significant infrastructure and staffing resources are needed to achieve this goal. “Historically, health care reimbursement did not cover the setup and maintenance costs associated with these resources,” Mr Argueso said. However, the Enhanced Primary Care Payment offers a capitated (per patient per month) payment to support care transformation activities. 

Currently, reimbursement for services is disconnected from the difficulty of treating patient populations with complicated needs, Mr Argueso continued. Generally, the lowest reimbursing insurers cover the most challenging patients, whereas the highest cover the healthiest. It is not surprising, then, that providers often decide to expand into markets that are already saturated with providers. 

“Clinical and social risk adjustment of patient populations changes this paradigm entirely,”  Mr Argueso said. “With this new system, payment for treatment to patients with high clinical and social needs will be greater than similar treatment for patients without these needs. In addition to helping advance health equity, this risk adjustment should reduce long-term costs to the taxpayer by reducing the proportion of expensive adverse medical events in underserved populations.”

In a Health Affairs paper, Joshua Liao, MD, and Amol Navathe, MD, PhD, examine the AHEAD Model’s potential to advance equity.² Dr Liao is the medical director of payment strategy at the University of Washington Medicine, where he is also an associate professor of health systems and director of the Value and Systems Science Lab in the School of Medicine. Dr Navathe is an assistant professor at the University of Pennsylvania’s Perelman School of Medicine. Both are fellows at the Leonard Davis Institute of Health Economics.

Dr Liao and Dr Navathe see a variety of encouraging aspects of the proposed equity strategy. “First, equity plans and quality targets can help ensure that payment policy implementation follows intention–and that disparity gap closures are prioritized rather than relegated to secondary unintended effects to be monitored,” they wrote. “Second, the emphasis on enhanced partnerships that extend to communities, as well as focus on health-related social needs screening, reflect the latest approaches to addressing social drivers of health.” 

Dr Liao and Dr Navathe also see the recruitment of safety-net organizations as another positive development. Traditionally, population-based programs have been hurt by the lack of participation on the part of these groups, which has led models to favor more affluent communities. AHEAD’s state-based approach, primary care investment, and improved alignment of incentives across Medicaid and Medicare could help encourage the participation of these organizations, they note.

Yet another aspect seen as encouraging is that “bonus payments will be linked directly to performance on disparities-focused measures–an approach that recognizes performance measurement and performance-based incentives as design tools for advancing equity in payment programs,” they said. 

Implementation Challenges and Unknowns

Can the discussed focus areas enable AHEAD to meet its ambitious aims and advance health equity via population-based care? Dr Liao and Dr Navathe think “the answer depends in part on implementation, and how AHEAD translates overarching strategy into model design.” Despite all the potential upsides, they and others believe there are plenty of lingering questions, unknowns, and challenges this model could encounter. 

According to Mr Argueso, one significant implementation challenge is the enormous organizational and cultural shift required. “Payment models based on global budgets or capitated reimbursement systems have completely different financial incentives than fee-for-service models,” he said. Within the existing system, the underlying incentive is to do more, considering every test and treatment leads to more payment to providers—regardless of the efficiency, efficacy, or patient experience involved. Most providers are accustomed to having these incentives in place. 

On the other hand, global budgets and capitated payments involve a fixed payment amount for a population that calls on providers to focus on reducing wasteful services. The incentive payments attached to this setup reward the improvement of outcomes and the reduction of disparities. “These are all different behaviors that require a significant cultural shift among everyone involved in care delivery,” Mr Argueso added. 

Another significant challenge, according to Mr Argueso, is related to the monitoring efforts meant to make sure patients are appropriately cared for. Because the AHEAD model involves financial incentives that may reward a reduction of services to patients, the model will include requirements to ensure that providers are not withholding necessary care. “This can be easier said than done,” he said. 

“Beyond the difficulty in balancing a fixed budget against treatment needs, robust data reporting capabilities are needed to track the financial and clinical information needed to attest to high-value care,” Mr Argueso continued. “Aside from the cost of the capabilities, the data reporting can eat into the time providers have to deliver services to patients.” Although AHEAD does include infrastructure investment programs, it is too soon to know whether the support will be sufficient. 

Dr Hennessey called AHEAD “an ambitious model” and emphasized that various unknowns could impact its success. “CMMI indicated that AHEAD’s fee methodology has considered the care offered by academic medical centers, including high-cost drugs and novel therapies, but participation by these entities remains to be seen,” she said.

Dr Hennessey also pointed out that “Total cost of care models require timely data aggregation, analysis, and sharing with network participants.” Participants in a different CMMI model called the Oncology Care Model struggled to obtain timely data that could help lead to well-informed decisions, according to Dr Hennessey. However, she remains hopeful that lessons learned from that model will result in improved data sharing.

“Robust sustainability plans will be required to replace startup funds available only during the model’s early years, raising questions about the model’s viability in subsequent years,” added Dr Hennessey. Furthermore, it is unclear how receptive self-insured employers and commercial plans will be to this new model, especially if there are adequacy and network recruitment difficulties. 

What Will Participation Look Like?

In many ways, the mission underlying AHEAD is aligned with other CMS Innovation Center programs, according to Dr Liao and Dr Navathe. Still, AHEAD is unique as a population-based model because it is designed at a state level rather than a care delivery organization level.

As CMS has suggested, AHEAD builds upon lessons learned from 3 single-state programs: the Maryland Total Cost of Care Model, the Vermont All Payer ACO Model, and the Pennsylvania Rural Health Model. “Each of these have components that have been incorporated into the AHEAD Model, giving CMS some confidence that its expectations are not outlandish and that states will participate,” Troyen Brennan, MD, an adjunct professor of public health at Harvard and a former executive at CVS Health, explained in a Health Affairs paper.³

But none of these models match up exactly, and from Dr Brennan’s perspective, some of the most significant questions relate to whether or not crucial stakeholders—private insurers, hospitals, and state governments—will participate. “The private insurers and the hospitals are only going to get on board if state governments are prepared to push hard to make the AHEAD model work,” he noted. “But how many have that drive and commitment and can reasonably sustain it over a 10-year period?” 

Some states, such as Massachusetts or Oregon, may be more inclined to take a close look at the opportunities provided by the AHEAD model because of prior work undertaken to address population health management or cost control. However, Dr Brennan predicted that states that have not already moved in these directions are less likely to seriously consider participation, even though they potentially have the most to gain. 

“Some states will take up the challenge and we will learn new things about improving care, addressing equity, and controlling costs—all of which will lead to a better health care system,” said Dr Brennan. “But a lot of challenges will have to be overcome, and our current experience with these kinds of reforms does not provide anywhere near all the answers.”

References

1. CMS announces transformative model to give states incentives and flexibilities to redesign health care delivery, improve equitable access to care. News release. CMS. September 05, 2023. Accessed February 14, 2024. https://www.cms.gov/newsroom/press-releases/cms-announces-transformative-model-give-states-incentives-and-flexibilities-redesign-health-care
2. Liao JM, Navathe AS. The AHEAD model and the potential to advance equity through population-based care. Health Affairs Forefront. October 30, 2023. doi: 10.1377/forefront.20231025.534260
3. Brennan TA. Three outstanding questions about CMS’s ambitious new AHEAD model. Health Affairs Forefront. Published September 14, 2023. Accessed March 4, 2024. https://www.healthaffairs.org/content/forefront/three-outstanding-questions-cms-s-ambitious-new-ahead-model