Lessons from Eliot Fishman, Director of the Policy and Programs Group at CMMI, on Medicaid from a Federal perspective

This episode is part of Pear VC's series on Medicaid, covering the basics that founders need to know to build innovations that support communities in need.

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Welcome back to the Pear Healthcare Playbook! Every week, we’ll be getting to know trailblazing healthcare leaders and diving into building a digital health business from 0 to 1.

This series aims to demystify Medicaid, starting with insights from federal and state agencies, FQHCs, and managed care organizations, before exploring successful founders' strategies. Read our primers on the key players and innovations here, and stay tuned for upcoming posts featuring interviews with key opinion leaders, purchasers, and startup founders.

Today, we're excited to get to know Eliot Fishman, a director at CMMI who focuses on policy and programs that affect Medicaid beneficiaries.

Eliot comes to us with a long history of impact in public health policy. Eliot started his career as a policy associate at Mt. Sinai Health System in NYC and then went on to Manatt, Phelps & Phelps. He transitioned into a management policy role on the provider side again at MJHS, a large health system in the New York Area before he left to join the government. 

Eliot then served at NJ Department of Health and Senior Services and Centers for Medicare and Medicaid Services for several years across different groups on Medicaid, Medicare and CHIP. Eliot also served in consulting roles at Health Management Associates and at nonprofits like Families USA.

In this episode, we learn about payment models within CMMI that attempt to foster innovation in care delivery for Medicaid, program and payment integrity and value-based care models as well as how the Federal government collaborates with State governments to improve care delivery.

We encourage you to listen to our podcast recording where we dive deep into all of the following sections.

Early Career and Experience

• Eliot began his career at a large integrated delivery system in New York City, focusing on managed care and long-term support services (LTSS) for elderly and disabled individuals needing assistance with daily activities.

• He gained significant experience with episodic payment methodologies in Medicare. For example, Medicare home health benefits use a 60-day bundled payment, meaning providers are paid a set amount per 60-days rather than per service, which encourages efficient utilization of services.

Medicare home health services offer part-time or intermittent skilled nursing, physical therapy, occupational therapy, and speech-language pathology for homebound beneficiaries. To qualify, a doctor must certify that the patient is homebound and requires intermittent skilled care. Medicare covers these services fully, except for a 20% coinsurance on durable medical equipment ​ (Medicare)​​

Value-Based Payment Models

Value-based care models shift the focus from the volume of services provided to the value of those services, emphasizing patient outcomes and cost efficiency. By aligning financial incentives with patient health outcomes, these models encourage healthcare providers to deliver higher quality care.

• Eliot discussed the evolution of value-based payment models in Medicare and Medicaid, focusing on the Home Health Value-Based Purchasing Program (HHVBP). This program provides financial incentives or penalties based on the quality of care provided.

Brad Smith's Retrospective: Eliot referenced Brad Smith's retrospective on Medicare and Medicaid payment reform, highlighting the need for better program designs and learning from models like BPCI and BPCI advanced to minimize gaming and enhance effectiveness​. There is bipartisan consensus on increasing accountability for cost and quality and major healthcare payment streams.

Policy and Program Integrity

• Eliot highlighted the challenges of maintaining program integrity while ensuring access to necessary services, such as Adult Day Health programs for the elderly. He stressed the importance of designing payment systems that minimize opportunities for abuse and require continuous monitoring and adjustments to prevent exploitation.

• Provider Revenue Maximization: Eliot noted that all major health systems, including non-profits, aim to maximize revenue while maintaining their mission. This balance affects how they respond to payment models, making it crucial to understand for designing effective value-based payment systems.

Program integrity in healthcare involves preventing fraud, waste, and abuse within payment systems. This includes ensuring that services billed to Medicare and Medicaid are necessary and provided as claimed. Effective monitoring and audits are essential to maintaining program integrity.

Forthcoming Innovative Payment Models for Medicaid

1. Behavioral Health

• Eliot elaborated on the new Innovation in Behavioral Health Model, which integrates primary care with behavioral health services to address fragmented care for individuals with serious mental health issues. Up to eight states will be awarded a cooperative agreement by CMS. When chosen, a participating state must pick practice participants who are specialty-focused behavioral health organizations or settings that, at the time of the application.

  • The model lasts for eight years including a pre-implementation period of three years during which funding will be disbursed and organizations will have the opportunity for capacity building.

• Specialized behavioral health practices will conduct screenings and assessments, provide necessary treatment, manage referrals, and monitor ongoing conditions.

• The model includes increasing Medicare reimbursement for behavioral health to improve access, as many behavioral health providers primarily serve Medicaid patients. Expanding Medicare coverage can enhance service availability. The model also requires participating practices to develop a health equity plan to address disparities.

2. Maternal Health

   

• Eliot introduced the Transforming Maternal Health Model, focusing on team-based and value-based approaches to improve maternal health outcomes which is a 10 year model with a 3 year pre-implementation period. Like the IBH model, 15 state medicaid agencies will receive targeted assistance and resources from CMS to improve access to a maternal health workforce.

• The model encourages states to innovate in maternal health care delivery, supporting comprehensive care that includes prenatal, postpartum, and even behavioral health services. Startups like Seven Starling which focus on maternal mental health and others are well positioned to provide value for Medicaid members under this model. Key components of this model are whole-person care delivery with health equity plans, improved access to maternal health providers like midwives, doulas and birth centers and a payment model to support them. Under this model, providers will work with the state medicaid agency to implement innovations and collaborate with community-based organizations (CBOs). CBOs will share data back and forth with providers to enable more efficient and personalized maternal health.

3. Sickle Cell Disease

   

   OBA stands for outcomes based arrangement

• Eliot also discusses a new Cell and Gene Therapy Access Model which focuses on outcome-based payment for expensive, innovative treatments like cell and gene therapy for sickle cell disease. These therapies involve high upfront costs but offer potential long-term health improvements.

• Outcome-based payment models link reimbursement to the effectiveness of the treatment, ensuring that providers and pharmaceutical companies are accountable for the patient outcomes. This can make high-cost treatments more accessible to patients who need them. Essentially, the insurer (Medicaid in this case) will be responsible to pay the full negotiated cost of the therapy at the point of care and will be entitled to progressive rebates from the manufacturer if the treatment does not meet mutually agreed upon performance goals (like long-term ineffectiveness or complications).

• In this model, CMS negotiates the outcomes-based agreements on the states behalf. Participating states will have the benefit of group negotiated prices on particularly expensive treatments that can cost upwards of millions of dollars.

GUIDE Model for Dementia Patients

• Eliot discussed the GUIDE model, which provides coordinated care and support for dementia patients. This model focuses on moderate dementia, offering care coordination and respite services to improve patient and caregiver outcomes.

• Dementia care often requires coordinated services across multiple disciplines. The GUIDE model aims to streamline this care, ensuring that patients receive appropriate support while reducing the burden on caregivers. By providing a structured approach to dementia care, this model can improve quality of life for patients and their families.

• The GUIDE model is unique because non-clinical caregivers are now part of the care team and go towards the PBPM. It starts with a risk assessment and then patients will be assigned to tiered intensity of care that is tied to payments. This model runs for eight years and is focused on care coordination.

CMMI's Role

• CMMI’s role: Eliot explained that the Center for Medicare & Medicaid Innovation (CMMI) tests new payment and service delivery models to reduce costs and improve quality, often targeting high-cost areas like chronic diseases and behavioral health.

• Federal-State Relationship and Medicaid Programs: Eliot emphasized the importance of state flexibility in implementing federal guidelines and the role of federal oversight in maintaining program integrity. CMMI collaborates with state Medicaid agencies to tailor innovative models to state-specific needs. The federal government must keep requirements simple and provide clear pathways to approval, with direct communication being crucial for effective federal-state engagement. CMMI also builds learning communities and shares knowledge and strategies.

• Payment and Policy Innovation: Eliot noted the importance of private sector innovation in informing national policy. Balancing ROI with long-term population health improvements is key, especially for interventions where the benefits are measured over a longer horizon, like those for children. Medicaid managed care contracts can build financial incentives that amortize long-term ROI into short-term benefits.​

• Health Equity and Social Needs: CMMI focuses on creating incentives and requirements to drive technology development for addressing social needs. Eliot suggested collaborating with ARPA-H to enhance Medicaid's approach to social determinants of health and digital health solutions.

Advice for Founders

• Eliot encouraged founders to directly reach out to CMMI via email, as regular interaction fosters productive mutual exchange. While CMMI provides extensive programmatic information online, direct outreach is essential for developing products that add value and have long-term support from CMMI.

• Founders can identify opportunities and unmet needs by analyzing programs with issues or failures, focusing on areas with bipartisan support for increased accountability in healthcare costs and quality. CMMI aims to bring value-based payment to previously untouched providers, especially in low-income communities, by expanding ACOs and advanced primary care models into Medicaid.

Interested in CMMI? Learn more on their website.

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