Flirting with models

In the film, The Devil Wears Prada, Anne Hathaway portrays Andrea, a novice assistant to fashion mogul Miranda Priestly (Meryl Streep). Miranda’s chief protégé and confidant, Nigel (Stanley Tucci), shows little patience for Andrea when, during their first encounter, he warns, “Don’t make me feed you to one of the models.”

In the 14 years since its inception, the Centers for Medicare & Medicaid Services Innovation Center (CMMI) has released more models than a Paris runway during Fashion Week. Payment and care delivery models, that is. There are 98 models and counting to be exact. Faced with such a barrage, it’s easy to see why state agencies often feel they’re being fed to one or more of these models.

Within the past 90 days alone, CMMI has found itself flirting with models again, releasing the following:

• States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model
• Transforming Maternal Health (TMaH) Model
• Innovation in Behavioral Health (IBH) Model

The aim of such efforts is noble and necessary – improved care, increased equity and reduced cost. However, states often find evaluating and pursuing even one or two CMMI models daunting. On a recent call with CMMI officials outlining these initiatives, several attendees voiced confusion among states about which models to pursue. Fallout from the pandemic and redetermination efforts have left state Medicaid staffs exhausted and stretched thin. What is a state Medicaid agency to do when lofty goals collide with ugly realities?

One answer is turning to trusted entities who for decades have provided Medicaid agencies with powerful tools to address payment and quality measurement initiatives. Another option might be looking at similar efforts from other states or CMMI models that have proven successful. For example, one innovative CMMI model of the past few years has been the Integrated Care for Kids (InCK) demonstration. Illinois Medicaid participates in InCK and is supported by data vendor Egyptian Health Department.

Egyptian had been relying on surveys completed by clients to determine appropriate risk categories. Egyptian’s Chief Information Officer Teresa Pickering recently said, “Using 3M CRGs, we're able to actually see the claims data. If the client says they’ve had some behavioral health issues or physical health issues, we’ve been able to verify that. Sometimes we find more complex medical conditions than are shared with us, and the client really needs to be in a higher risk category.” Reducing avoidable hospitalizations or ED visits is another example of learning from the experience of others, and such learnings offer value for any of the three recently released models.

With its collection of myriad payment and care delivery models, CMMI has created a marketplace of innovation and experimentation where only worthy, scalable ideas survive. Unfortunately, many of these models haven’t and won’t meet their stated objectives. (We’ll put those in the Charles Barkley, ‘I’m not a role model’ category.) However, the handful of groundbreaking initiatives that endure the state vetting process over the coming years should offer impactful and lasting change for providing and financing large chunks of the country’s health care. The goal will then be to convert these successful models into role models for all U.S. states.  

Clark Cameron is director of payer commercialization at 3M Health Information Systems.