Rae Woods:
From Advisory Board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae.

Rae Woods:
Today, I wanted to bring you a conversation with an agency that typically keeps things a little bit close to the chest. I sat down with Liz Fowler, the director of the Center for Medicare and Medicaid Innovation, or CMMI. We talked about a lot of the success of the last decade of innovation, and frankly, where the agency has fallen short to date. But most importantly, I want you to listen for what Liz and her colleagues are thinking about for the next decade of innovation.

Rae Woods:
Welcome Liz to Radio Advisory.

Liz Fowler:
Thanks Rae, and I'm so happy to be here.

Rae Woods:
Do you ever go by Elizabeth or do you just go by Liz?

Liz Fowler:
I go by Liz.

Rae Woods:
Does anybody call you Elizabeth?

Liz Fowler:
My mother but only when I'm in trouble.

Rae Woods:
Okay. I'm clearly asking because right, my name is Rachel and everyone professionally now calls me Rae but I have this existential crisis because I truly go by both names and I clearly could ... I just couldn't pick a lane which is why I always introduced myself as both. So I wasn't sure if you fell into the same boat.

Liz Fowler:
Well it turns out there's another Elizabeth Fowler at HHS who is leading the Indian Health Service, and so it's critical that I go by Liz and I believe she's going by Elizabeth. We have some confusion on emails as you can imagine.

Rae Woods:
I want to start with your honest opinion. There has been a lot of change in healthcare over the last decade, but tell me honestly, has healthcare changed and transformed as much as you thought it would or maybe as much as you hoped it would?

Liz Fowler:
Looking back, remember that the CMS Innovation Center was part of the Affordable Care Act, and the Affordable Care Act, I think the coverage pieces, we got a lot of expanded coverage which was really important. On the delivery of system reform side, I think maybe not as much has changed as we had intended. I think we thought we would be a lot further along from the prospective of the Innovation Center really after launching more than 50 alternative payment models, really only a handful of those models generated the savings that was required to be expanded under the statutory framework.

Rae Woods:
That's right.

Liz Fowler:
It's a marathon, not a sprint, I guess.

Rae Woods:
And I think this is one of the reasons why we're actually sitting down, having this conversation, because you and your colleagues are kind of coming at innovation through CMS with fresh eyes and you co-authored a piece that took an honest look at some of the successes but also a lot of the challenges that have remained over the last decade and one of the first things that you point out is that models to date maybe weren't actually centered in equity. So to start, what are some of your plans to make sure that you're encouraging a more diverse set of providers actually participates in these alternative payment models?

Liz Fowler:
It's a really critical question because it's such a priority for this administration. So it's really important that we get this right. So we're looking at embedding equity into all aspects of our models, in terms of model developments, who is coming to the table, who is participating, making sure that we have a safety net, we're all providers, that we're not disadvantaging some of those that haven't come in in the past. We're looking at what beneficiaries they serve, even if they're sort of broader model participants, are they enrolling beneficiaries in all parts of the country or is their selection area broad enough to encompass underserved populations? Then we're making sure that we have the data and asking the right questions for example on social determinants of health so that we'd be able to evaluate whether we're actually making a difference in health equity. So those are some of the ways that we're thinking about it and really I think by making it a focus, hoping we can make a dent in the health disparities that we've seen under COVID.

Rae Woods:
Yeah, and this is really important because when we talk about health equity, which frankly we talk about a lot on this podcast, we talk about unintended consequences. We talk about the fact that a lot of folks have really positive efforts but unintentionally may be influenced, like in this case, the kind of provider that could actually experiment with new payment models. That said, I actually do think that there are some specific steps that the last two administrations have taken to create some intentional differences. If I think about the Obama era, it was all about participation. Let's get as many providers to experiment with new models as possible, and you know what? It's okay if they're not getting into downside risk or maybe not saving the federal government all that much money. I think the Trump administration took a different tactic and they really focused on performance. They wanted to target the providers which were mostly physician groups that were actually taking on meaningful risk. So when it comes to this balance of participation on one end and performance on the other, where do you see the Biden era?

Liz Fowler:
In my view, and this is my opinion, the approach taken by the two previous administrations isn't really that different. Yes, there's some differences. The Obama administration focused on getting models out the door, proverbial spaghetti against the wall, and the Trump administration was focused on providers taking on risk, but I chalk that up to the fact that when the organization was in its infancy, you wanted that spaghetti on the wall, and then once we started getting results from the model tests, it makes sense to focus on savings and results and risk. Now if I was to describe the priorities of the Biden administration, it would be a focus on transformation. So taking what we know, all of the lessons learned, and figure out how to lay out a more clear path towards healthcare transformation. Focus on the patient experience in the healthcare system, focus on equity, and then also really thinking more about working with commercial payers, purchasers and states in this sort of multi-payer alignment. Can we really expand the impact?

Rae Woods:
Yeah, I like that word impact actually, because you're right, we can't do spaghetti at the wall forever, and if we know that a decade later, we need to make sure we're making a meaningful impact, and not just for those that can kind of participate, back to our comments about equity, it sounds to me like I'm going to use the term turning up the heat is something that CMMI wants to do to make sure that we're getting the performance that's necessary.

Liz Fowler:
Yeah. I think that's one way to put it. Yeah.

Rae Woods:
So we know we want to focus on what works and one of the things that you acknowledged is that maybe we just tested way too many models. I think you said 50 models were tested, I want to say almost 30 are actually being used right now. I think we could all agree that isn't actually doing any favors for the sanity of providers. So are you planning on turning anything off if we know we need to make an impact, what are you going to be deprioritizing?

Liz Fowler:
Well, you have that right. We're currently operating about 28 models, and we know that they create opposing incentives, they lead model participants to have to really think about how to manage model interactions. So we want to increase participation in the models and we want to avoid the types of complexities that lead providers to have to manage shared savings, for example, who gets the savings if you're in more than one model. We're really thinking about focusing on a set of criteria for models in the future. Thinking about factors like does the model support or advance one or more of our strategic objectives? Driving accountable care, health equity, supporting innovation, addressing affordability, or this idea of partnership. We want to think about the potential impact, so really thinking about the potential for savings, for quality improvement, these seem kind of obvious, but also the potential for other payers to be partners in the effort, and then also, once the likelihood of being able to scale this model across the country.

Liz Fowler:
So even by non-participants, and I know this is maybe a little inside baseball for inside CMS, but we want to make sure that we're working more closely with other parts of CMS, like the Center for Medicare and the part of CMS that runs Medicaid, so asking them are we asking the right questions, are we going where innovation is needed in those programs, and this might increase the likelihood that the results of the models can be incorporated back into the program.

Rae Woods:
So you've got this system of ... I'm going to use the term grading. Looking at what we're offering and figuring out does it actually meet all the aspirations of this administration, of this new leadership team, but are there kind of broad, sweeping takes that we can interpret from that? I'm thinking about episodic payments, bundled payments, total cost of care models. When you look at those broader categories, do you have thoughts on which of those models get turned up or down if you know that 28 is too many?

Liz Fowler:
So accountable care, the notion of these total cost of care models are going to be really primary and center to the strategy. I think in terms of how we think about the bundled payments and the episodes of care, they're still important, but we want them to be working in coordination or harmonized with total cost of care. So we're asking ACOs, we're talking to providers and health systems out there like how those programs can be better integrated. So what do ACOs need in terms of managing episodes of care and some of what they're telling us is can you focus on the sort of very high cost, low volume things that primary care isn't as equipped to manage. So don't go into diabetes, we don't need a diabetes episode, but oncology is an area, some of the very high cost, very I guess complex cases, where having a solution would be helpful and complimentary to what they're doing.

Rae Woods:
I saw some comments from one of your colleagues, the COO of CMMI, John Blum, and he had said in a conference something along the lines of we're not going to be promoting models that have more risk just for the sake of having more risk, and in that comment, I actually saw a bunch of different interpretations come out, one of which was even in modern healthcare, where some were saying, "This means that CMMI is going to actually turn their focus away from downside risk. They're going to double down on coding, on risk adjustment." Now that's obviously an interpretation. How do you want us to think about John's comments there?

Liz Fowler:
Well thanks for bringing that up because I heard a lot of feedback after his comments. I think it was at the [inaudible 00:11:15] meeting. I think there's a difference of opinion about how important risk is in this sort of ability to transform the health system. There is a difference of opinion externally and there is a difference of opinion internally as well, and in my view, I think risk is an important element, but not everybody's ready to get there. So I think CMMI's role is making sure that there is a place for those that want to go and bear more risk that are ready, willing and able, that are resourced and have the capacity and the tools to do so, and then how can we bring others along who haven't put a toe in that water and might not be ready. So I think for us, it's thinking about a continuum of options. So maybe not a one size fits all. On the other hand, we have to reduce the complexity. So not 50 options either, so can we get it down to a manageable number of options? But I do think we need to have those options for those providers and systems that want to bear the risk, and then getting those in at the front end as well.

Rae Woods:
You mentioned the word scale earlier, and I think that figuring out how to scale these models is actually perhaps even harder than figuring out which kinds of models to focus on, and when it comes to scale, the obvious question is what's going to be mandatory? What are providers going to have to do? Where do you see mandatory models playing into your plan for achieving scale?

Liz Fowler:
Yeah, we've been giving this a lot of thought too, and just like the question of risk, I think there's also disagreement about whether we need mandatory models in order to drive success and I think again, in my view, mandatory models do have a place in our portfolio and we should consider them, but they need to be as I mentioned interacting with total cost of care approaches.

Liz Fowler:
So we've got two mandatory models that are moving through the regulatory process, the knee replacement and radiation, oncology. Others, I think we're debating and discussing models internally. Some are telling us that if we don't have mandatory models, we're leaving out a whole swath of the health system that will just sit on the sidelines and decide they don't need to make any progress, and I think we don't want that. On the other hand like I said, we're looking at how we can make sure that these approaches are harmonized and working in conjunction with total cost of care. So maybe that's the longterm and we will need some models that look at mandatory participation in the short run.

Liz Fowler:
This gets to the question of participation too, and making sure that we're incorporating safety net providers, rural providers, others that maybe haven't had the tools and resources and the capacity, and making sure that they're ... We're not forcing them into models where they're set up to fail, but we're also bringing them into the fold. So with the voluntary models, the ones that participate are the ones that are going to be successful, we want to make sure that we're capturing a broader swath but we also want to make sure we can set them up for success.

Rae Woods:
So because there's internal debate, and because you have these other goals that you're trying to hit in the backend, is there a sense of the kinds of mandatory models or maybe the kinds of providers that you would want to target for those mandatory models? Is there a thought or a consensus on that?

Liz Fowler:
I think those issues are all under debate and it's kind of hard to target certain kinds of models because mandatory tends to look at geographic areas. So within a geographic area, they'll cover providers in that area. And by the way, we also hear from some providers that they ... Five years ago, wouldn't have agreed and they would have opposed mandatory models. Now some of them are even welcoming it. We've even heard from providers who now that we're moving from voluntary to mandatory are finding themselves outside of the surface area and not part of the geography that's being tested and they're asking us can they come in on a voluntary basis because they liked being part of the model. So I think that's a change. So if you asked if we're making progress, that seems to me to be some progress.

Rae Woods:
Well, let me reveal to you what providers tell me. So I've been at Advisory Board for seven years speaking to mostly provider executives and this has been a key topic over those last seven years and if I think back to 2014, there was this kind of certainty that people spoke of when they thought about business model transformation. Risk was coming, value-based care was happening, they were making changes to not just their business model but to kind of the practicalities of operations. If I'm totally honest with you Liz, seven years later, I almost feel like the folks that I've talked to have slowed down in their thought process. They're still talking about value-based care, but they're talking about it still as this far off ambition. This thing that's going to happen in the future. They're happy to bide their time or hang out at upside only risk, and that's where it comes to how do we push these folks to not just get into alternative payment models but to actually take on meaningful downside risk? Are there other ways maybe beyond the mandatory that you're thinking about to push providers to actually take financial accountability for these models?

Liz Fowler:
Yeah Rae, what you're hearing is consistent with what we're hearing and we think that's a problem. Between the pandemic, momentum towards value-based care has really slowed. Part of that is on us. We haven't been really clear about where we're heading. The path we're taking or where we're ... What's the ultimate destination, and I think that clarity has been missing and so in the time that I have in this job, really I think my job is twofold, to provide that clarity and lay out that strategy and that future direction and then also help us regain that sense of inevitability and I think that's really important, and that's why I think this notion of partnership and working with other payers and purchasers and states is really important. Even if you have a provider that is willing, ready and able and participating in some of our models, they're still missing other payers who are part of that. So they've got one foot in two boats. So even the ready, willing and able partners could use that help from us to help push the other payers in the system to get on board and join this momentum and movement.

Rae Woods:
How important is that? I'm thinking that again, if I think about some of the more pessimistic conversations that I have with providers, they're saying big change isn't going to happen until the private payers actually get on board. How are you seeing your efforts now as pushing private insurance to follow in the path of CMS, or maybe how necessary is that for the kind of broader change that we're talking about.

Liz Fowler:
Yeah. I mean I think Medicare has to be at the table. Like Medicare is a catalyst for a lot of the changes, but we can't do it alone like you said, and so we really need those private payers and it's really interesting. When we ask stakeholders why isn't more progress being made, the providers say, "Well because the private payers aren't pushing us hard enough, and they're not doing anything," but then you ask the payers and they say, "Well our purchasers aren't pushing us hard enough and providers don't want to go there and they're not willing to take risk." So everybody sort of points a finger at everyone else, and that's where laying out a strategy and a vision and a path forward I think is really critical and it's exactly why I want to do more of these podcasts and why I've been doing a lot of public speaking is just really trying to see if we can get that momentum restarted.

Rae Woods:
This in my opinion is the hardest part about your job is that you recognize that on the one hand, there is a very clear need for more momentum. We need to push providers into the deep end of downside risk. Otherwise, the private payers are still going to say, "See? They're not interested in doing this," and pointing that finger. But at the same time, you know that you need to give those same providers the tools to succeed. Perhaps even new and more tools to succeed. Otherwise we're going to get the same type of provider jumping in, and if that's going to affect our equity goals. So the question I have is how? How do you balance those two things and build that necessary momentum while also giving people the tools to actually succeed?

Liz Fowler:
We faced a lot of the same challenges, I worked on the Affordable Care Act. I was the chief health counsel in the Senate finance Committee during the drafting of the ACA. We faced a similar challenge, but as soon as you can create that sense of inevitability, then people want to come on board. They want to be part of the solution, and so I feel like we're at a moment in time where we need to do that. We need to restart that engine on value-based care and I think we can, and part of my job is just to serve as cheerleader. There are so many healthcare issues out there right now. Congress is debating a reconciliation bill, drug pricing, adding new benefits to Medicare, expanding coverage in states that haven't adopted Medicaid. There's so many issues on the table that somewhere value-based care gets lost and it's my job with colleagues and the rest of CMS leadership but my job is sort of singularly focused on these issues, so that's why I'm spending a lot of time talking to as many people as I can.

Liz Fowler:
And by the way, I wouldn't say that I have a solution for all of this. We're sort of building the plane as we're flying it. Which is also what we did during ACA as well. We didn't know where that [inaudible 00:20:36] was going to end, but I think as long as you remain optimistic and positive and keep that cheerleader approach going, you're more likely to succeed.

Rae Woods:
You keep mentioning this sense of inevitability. Getting back to this sense of inevitability that change is going to happen. What is the plan to create and kind of resurface that sense among today's providers?

Liz Fowler:
Well, I don't know that I have a clear answer on how to do that. I think it's going to require partnerships and work with other payers and purchasers and with states. I don't know, this is not a great answer, so ...

Rae Woods:
I mean maybe the answer is we don't know and we want to know from the providers what would create this sense of inevitability, especially since we kind of maybe had it and lost it a little bit.

Liz Fowler:
To be totally honest, I think there's a time where we might need further legislation. There might need to be further legislative changes. I mean if you're going to make fee for service as uncomfortable as possible, while you're providing these other alternatives, as I look at the current statute and all the regulations, I'm not sure we can get there with our current framework. So you need cheerleaders, you need partners, you need the systems and the providers on board, but at the end of the day, we might also need to look back and see what legislative changes helped get us there.

Rae Woods:
Yeah, I totally agree, and I actually think you're spot on with saying that we need to make fee for service as uncomfortable as possible. Because gosh, especially now, if there's one thing that providers want, it is a sense of comfort given everything that we've gone through in the last 18 months and that will create some real stagnation in some of our efforts for transformation. So I think it's both, how do you make these risk models more attractive and how do you make the status quo fee for service as unattractive as possible?

Liz Fowler:
And you raise a good point. COVID shows you how dangerous pure fee for service is when volume drops so precipitously, and it was providers that were in this space in value-based care that had made those investments that did a better job that were more resilient, and so I think some of us were hoping that that was enough of a push to sort of restart the engine, but I think more is probably needed. And there's a lot of providers that are really struggling right now. I mean COVID has been ... Bless and many thanks to all the providers at the front lines of providing care in the middle of a pandemic, and so this is in some ways a bad time to be asking them to make this leap but in sometimes maybe a good time because you can see the value of that leap.

Rae Woods:
Yes. If I give some credit to providers who I'm speaking to, if I think back to the start of the pandemic, there were a lot of folks that said that COVID-19 was going to completely accelerate the transition to alternative payment models because of exactly the reason that you pointed out, and I think that some of that momentum has naturally been lost but that is a reason to double down now and say, "Hey, it wasn't that long ago that you saw how painful a complete reliance on volumes was. We want to make it easier for you to get in some of these risk-based models as well."

Liz Fowler:
Yep.

Rae Woods:
Now there's something that's in the back of my head during this whole conversation, which is that we know that the Medicare Trust Fund is slated to run out in 2026, and I know that value-based models were never going to fix our insolvency problem. In fact I don't think that they were ever intended to necessarily do that, but are you thinking about adjusting value-based models to better support the trust fund?

Liz Fowler:
Well some of us did think that value-based care could be part of the solution, so the Medicare Trust Fund solvency date is now 2026. Only five years away. It's better than some of us expected, but it still adds some urgency to the task before us. As I see it, we have five years to make progress on value-based care. We have to demonstrate that there are ways of generating savings and improving quality and outcomes. What happens if we don't succeed? Congress comes in with a budget bill that cuts payments across the board, whether you're a good provider or a bad provider. So in my mind, solvency is like a sword of Damocles, and having spent time on Capitol Hill working on federal Medicare policy, I can assure you the industry would rather make progress on value-based care than face a budget bill which as you said we might do anyways but let's see if we can make progress in the next five years.

Rae Woods:
But is five years enough time? I mean we're talking about reflecting on the last decade of innovation and we're having an honest conversation about what didn't work. So is five years even enough time to make progress?

Liz Fowler:
Yeah, it is a short window, and considering how long it takes, now I've learned how long it takes to get a model out the door and it's 18 months to two years from the point of sort of conception to launch. So if you think about that and then the ability to make progress and then evaluate the results, it is sort of a long runway but there are things out there where we know we can make progress, so I don't want to give up and just throw up my hands and say, "Well in five years we can't do anything." We might as well try.

Rae Woods:
Which comes back to the kind of theme of this entire conversation, which is we need to figure out how to create the sense of inevitability and build this momentum among providers and you've blatantly said that your role is to communicate that and be the cheerleader for that. So I want to give you the chance to speak kind of directly to the providers and the provider leaders who are listening to this podcast. When it comes to the next five to ten years of payment reform, when it comes to this push towards true business model transformation, what is the biggest thing that you want our listeners to hear from this conversation and what do you want them to do differently as a result of listening to this?

Liz Fowler:
I want to hear from them and so we'll do our part to try to provide that clarity. Like I said, this is a plane that we're building as we're taking off, so we've put out a blog, we're hoping to put out a whitepaper. We're going to put out more on sort of what we're thinking for models over the next two to three years. I would love to hear from providers, from your audience what's worked, what hasn't. What does transformation mean to you? What hasn't been working with us? What would you change? What should we do differently? And your reaction to the strategy and I think having that dialogue and that open communication, if we got to a point where I could do site visits and the team could go out and learn and visit providers directly and hear from them directly, that would be even better, but in the meantime, we're an open door and want to hear from folks.

Rae Woods:
Yeah. I will say, listeners, take Liz's word. Honestly, respond to this episode and Liz, maybe as you do more over your tenure, we'll have you back on to talk about what the next phase of payment innovation means.

Liz Fowler:
I would really appreciate that, and then maybe as that plane is flying, we can tell you a little bit more about what we're doing and what we're seeing.

Rae Woods:
I love it. I will take that as a promise.

Liz Fowler:
Please do.

Rae Woods:
Well Liz, thanks so much for coming on Radio Advisory.

Liz Fowler:
Thanks so much for having me.

Rae Woods:
We'll be right back with a little bit of a debrief on my conversation with Liz, with my colleague and strategy expert, Ben Umansky.

Rae Woods:
Ben, welcome back to Radio Advisory.

Ben Umansky:
It's been a while.

Rae Woods:
It has been a while, but I'm glad we brought you in for this conversation which was a big one for us and I think for you who's been following what CMS has been doing since pre-ACA.

Ben Umansky:
Oh yeah. This has been a topic of interest of learning and confusion and of oceans of all kinds of things for well over a decade at this point. So it's nice any time we're talking about it, and especially to get the perspective from someone with as much influence and as much authority to push at least some things in certain directions as Liz.

Rae Woods:
Well I want to get into what you thought about our conversation and I want to start with an area where Advisory Board has been thinking for a while. I mentioned that we have been thinking about this dichotomy between participation and performance, what the Obama era did, what the Trump era did, and what the heck it's going to mean for the Biden administration. What did you think about Liz's answer about participation versus performance?

Ben Umansky:
Sure. Well one thing that I think is really important that she said, and I want to make sure people catch this, that distinction, participation versus performance is not a political shift. I mean the fact that the Trump era did things in a certain way, let's remember that that was after years of data being piled up on these models.

Rae Woods:
That's right.

Ben Umansky:
So you were in a position at that stage, as we are again today, to be a little bit pickier and to say we're going to push here and not there, and to not be continuing to boil more spaghetti to use your metaphor. So I don't want anyone to think that there is a kind of ideological split between the performance and participation. But as far as where we can expect this administration to come down on that debate, I think you did hear a little bit of a hedge, and I think that's fine. You heard a lot of talk about getting more kinds of providers in different geographies, different types of organizations, to be participating in whatever model. But you heard about the solvency of the trust fund and the short timeframe to make an impact. You heard the self-critique which I think at this point must be an obvious one that not all of these bottles have actually generated savings and they need to start doing that or else we shouldn't do it. So it's not that you have to choose between participation and performance, but they are potentially different goals to prioritize I guess.

Rae Woods:
Yeah, and I said this to Liz is that I appreciate the level of ... Or the attempt at transparency in saying here's what we know didn't work over the last 10 years. But I'm not sure that Liz shared everything or perhaps knows everything about what's to come for the future. In your mind, what's the most important thing that Liz did not say? What did she leave out of this conversation that kind of perked your ears?

Ben Umansky:
I don't think that things were intentionally withheld if that's what you mean.

Rae Woods:
No no no.

Ben Umansky:
But as far as perspectives that maybe still remain unclear, I thought there was a very telling set of conversations that you had about this sense of inevitability. This recognition that providers need to think they need to do this. Whatever version of this we mean, providers have to feel as they did a decade ago, that it's going to happen and better to get there quickly, and what I didn't hear was a clear sense of how to recreate that idea, and I don't know if it can be done, to recreate a mood, almost in a nostalgic sense. I don't know if that can be done, I thought it was telling that she recognized the importance and telling that there wasn't clarity on how to recreate it.

Rae Woods:
And it sounds like maybe there's even some disagreement internally on what's the best path to reignite that sense of inevitability that you and I haven't seen in several years.

Ben Umansky:
There was one bit that I think is especially telling and that was ... I believe her phrase was we need to make fee for service as uncomfortable as possible. My gosh. I mean that's ... We think a lot about how these models are or are not, [inaudible 00:34:09] models are attractive or not attractive, are they easy to use, do you want to sign up for them, are they mandatory or not. All on the value-based side. Let's remember that it's a switch away from something else, and the attractiveness of that world matters just as much for strategy.

Ben Umansky:
Now Liz Fowler is not going to have the same kind of authority that Congress would let's say, she talked about setting a budget bill over the overall fee for service structure necessarily. But it was interesting to see that acknowledgment, that that side really does matter.

Rae Woods:
Well the other piece of acknowledgment that she gave that I appreciated was that's kind of outside of her personal purview is the acknowledgment that we need to get private payers on board. That there's only so much that can be done inside Medicare and Medicaid to push providers towards this, and that's maybe one of the reasons why things have stalled over the last 10 years.

Ben Umansky:
Yeah. Stalled, or ... This is the carousel, the catch-22, the chicken and the egg, pick your metaphor.

Rae Woods:
Yeah, pick your analogy.

Ben Umansky:
Where everybody says I'll do it when they do it and they won't do it until ... Private payers are businesses. They're not governments, they have different aims. Providers are businesses, even if they're not for profit. They have different aims, and the idea that because one side of the industry moves forward, if forward is even the ... That's sort of editorializing, but moves toward a value-based care, it's unclear why that has to catalyze somebody else to follow, and I think the last decade has shown that Medicare's intent that providers hedging attempts to lay a foundation are not enough in and of themselves to change private sector reimbursement. Other things need to change and that's probably a topic for another time. But that's a big lift for [inaudible 00:35:59].

Rae Woods:
It speaks to why creating that sense of inevitability is such a challenge, because it's going to mean getting over this barrier of every stakeholder in the industry is pointing fingers at one another or let's be honest, have currently opposing incentives and that is a reason why reigniting the sense of inevitability is going to be so hard for them.

Ben Umansky:
One other thing that I thought was very interesting and to some extent encouraging but maybe a little concerning as well was this broadening of the goal set. That of course we're concerned, says CMMI about saving money, [inaudible 00:36:40] for the government, but we're also concerned about giving people an on-ramp, which we know back in participation versus performance means maybe you do things that aren't as hard-edged. We're also concerned about patient experience. We're concerned about equity. And so you wonder what is the most important goal.

Rae Woods:
Especially given that one of the takeaways of the last 10 years is we thought too broadly about in this case model types and we needed to scope things back. But now they're kind of saying we're thinking a little bit more broadly on these big picture goals and I do wonder if you're right, if that's the best move.

Ben Umansky:
Well, to be sure, patient experience and health equity are hugely important aims, and policy should support those. But if the goal is to set a very clear direction, to leave no doubt about where Medicare is going and where providers had better follow, if that's the sort of emotional goal, saying, "Well maybe we'll measure success with this or that or whatever," it fuzzes that a little bit. So I'll be watching very closely as we see see this expected [inaudible 00:37:52] down of the models, the focus on certain things, what kinds of stuff does get launched going forward. To see if we can discern which goals truly matter most, and I don't think that's clear from this conversation. I don't think it's clear from some of the other comments that have been made.

Ben Umansky:
One thing that I will say, this has been I think a fairly vocal administration the first few months about where they want to see some things going, but that's not what's going to matter. What matters is what models actually get sustained, where they turn the screws, what stakeholders they cater to in the design, and we're not at that point yet.

Rae Woods:
And given that there is still uncertainty and given that as Liz said, they are still building the ship as they are trying to sail it, what takeaway do you have for our listeners?

Ben Umansky:
I think, and I'll speak particularly to the provider side audience although I think it probably applies to all, we're still going to need to sweat the small stuff. These models, conceptually, we can talk about total cost of care, we can talk about the migration to value. But they do specific things, and the terms will matter, and it seems likely that for years at least, we're going to be in a world where you have a lot of options to participate in some things and not in others. To push forward, to lag back. To work with some partners and not with others, and you're going to have to ... If you're a strategist, if you're a financial leader, if you're anybody who has authority over this stuff, you've got to pay attention to what the actual terms of these [inaudible 00:39:23] including on the private side. Because we can all say we like the concept of value. Everyone says that. That's why we see this disconnect where payers say, "Oh, we want to do it and they don't," providers say, "Oh, we want to do it and they don't." Everyone agrees on value. Nobody agrees on the terms.

Rae Woods:
Yeah. Well Ben, thanks for coming back on Radio Advisory.

Ben Umansky:
Any time.

Rae Woods:
My biggest takeaway from what both Liz and Ben shared is that we have to get a lot more specific in what we're trying to achieve here. That is going to be essential for creating that inevitability towards alternative payment models, and it's going to be important if we're going to stop pointing fingers at different parts of the industry and make sure that we're actually making progress towards alternative payment models. This is not easy, but that's why we're here to help.