Understanding the CMS 2022 Strategic Plan:  Six Trends to Follow

07.11.2022

The Centers for Medicare and Medicaid Services (“CMS”) issued its 2022 Strategic Framework (“CMS Strategic Framework”) on June 8, 2022[1]. Although styled as an open letter and visionary plan, key trends affecting providers now and in the future can be gleaned from a close look at the CMS Framework. From forecasting that almost all Medicare and Medicaid beneficiaries will be in an Accountable Care Organization (“ACO”) by 2030, to increased scrutiny of staffing levels in nursing homes to bold behavioral health projects, this article discusses the Top Six CMS objectives likely to directly impact healthcare providers.

  1. Medicare and Medicaid Beneficiaries Will Be Moved to ACO Contractors by 2030. The CMS Strategic Framework discusses the work of its Center for Medicare and Medicaid Innovation (“CMMI”) to build a “health system that achieves equitable outcomes through high-quality, affordable, person centered care.”1 CMMI’s goal is described as “launching models that increase the number of people with Medicare and Medicaid in accountable care relationships.”

    Related CMS Actions: CMS announced a new ACO model called “REACH” (Realizing Equity, Access, and Community Health) in February, 2022, and, in the same month, released a Request for participants to submit applications.[2],[3] In addition, CMS’ Innovation Center aims to increase the number of beneficiaries in ACOs, and plans to measure its progress by having all Medicare fee-for-service beneficiaries and almost all Medicaid beneficiaries in an ACO by 2030.[4]
  2. Providers Will Be Subject to More Pre-Authorization Processes. The CMS Center for Program Integrity describes “enhancing program integrity oversight” as including “increasing the use of prior authorization.”1 The longstanding enforcement policy behind greater utilization of pre-authorization programs is, as described by CMS, to avoid “playing world’s largest game of whack-a-mole” by monitoring new areas of risk with tools that include prior authorization programs.[5]

    Related CMS Actions: CMS has four prior authorization initiatives currently in place: Prior Authorization for Certain Hospital Outpatient Department (OPD) Services, Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT), Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items, and Review Choice Demonstration for Home Health Services.[6] CMS has not yet articulated how it will increase the use of prior authorization processes or for what services, but key concepts for providers will be how CMS can increase prior authorization while not adding to provider burden or blocking beneficiary access to services.[7]
  3. Nursing Home Staffing Will Continue to Be Scrutinized. CMS’ strategy for nursing homes continues along a familiar pathway: “having every nursing home employ a sufficient number of staff who are adequately trained to deliver high-quality care.”1

    Related CMS Actions: President Biden announced at the beginning of 2022 that his administration seeks to impose a federal minimum staff level on nursing homes.  However, with the current workforce shortages, some say this goal is currently unrealistic.[8]  In the meantime, in order to highlight the need for adequate staffing, CMS announced in January 2022 that it would begin posting weekend staffing levels and staff turnover on its Care Compare website.[9]    In July of 2022, CMS will increase transparency by adding employee-level staffing data for all nursing homes to Care Compare data.[10]
  4. Expect Avalanche of New and Revised CMS Regulations. CMS describes its initiatives for the post-pandemic world as including “releasing and/or updating regulatory and sub- regulatory guidance” and “restoring the minimum health and safety standards needed to improve quality across the continuum of care.”

    Related CMS Actions:  CMS’ plans could be called the “great unwinding” of its waivers and flexibilities that were provided during the pandemic. As a starting point, in April of 2022, CMS announced it was phasing out certain waivers and flexibilities for nursing homes, inpatient hospices, intermediate care facilities for individuals with intellectual disabilities (“ICF/IIDs”) and end-stage rental disease (“ESRD”) facilities.[11] The expiration of the Medicaid “continuous coverage requirement” will also expire at the end of the pandemic, with CMS issuing guidance to States on returning to regular operations and fears millions could lose Medicaid coverage.[12],[13]
  5. CMS’ Efforts to Ensure Prescription Drug Accessibility Will Include Increasing Use of Generics, Biosimilars, and Interchangeable Biologics. CMS plans to “improve affordability” of prescription drugs by “increasing the use of generics, biosimilars, and interchangeable biologics.”

    Related CMS Actions: The FDA allows “interchangeable biosimilar products” to be “substituted without the intervention of the health care professional who prescribed the reference product, much like how generic drugs are routinely substituted for brand name drugs” (subject to state pharmacy laws).[14] One indication of CMS’ push towards biosimilar products is reflected in a May 2022 Medicare Learning Network Newsletter, wherein CMS informed beneficiaries that they may “substitute an interchangeable biosimilar product at the pharmacy, much like substituting a generic for a brand-name drug” (depending on state pharmacy laws).[15] CMS also provided resources to educate health care students on biosimilars and interchangeable biosimilars in May of 2022.[16]
  6. Expect CMS to Vastly Improve Access to Behavioral Health Services. CMS plans for its Behavioral Health Strategy to cover multiple elements, “including access to prevention and treatment services for substance use disorders, mental health services, crisis intervention, and pain care.”1

    Related CMS Actions: CMS’ many plans in this area include: testing payment models that would integrate mental health and substance abuse treatment into primary care settings; expanding access to mental health support in schools by increasing access to Medicaid reimbursement; offering states the option to provide community-based mobile crisis intervention services, and providing for the continued payment of audio-only counseling and therapy services after the pandemic (where audio/video is not available).[17]

CONCLUSION

The Six Trends to Follow set forth in this article is only the tip of the iceberg on CMS’ radar for extensive changes and modifications to its policies, goals, enforcement, and reimbursement coverage for the next year. As CMS’ strategies and initiatives continue to evolve, please let us know if Nexsen Pruet can assist you in navigating the changing regulatory landscape.

This is an article from a series on Effectively Responding to Payor Audits & Program Integrity Investigations. Topics in this series include practical advice and legal developments for providers defending payor audits and investigations, plus articles concerning current audit and investigation targets and the various types of auditors reviewing claims and conducting investigations. The Series covers topics of interest to all providers of health care services, including hospitals, hospices, home health agencies, skilled nursing facilities, DME suppliers, clinical laboratories, pharmacies, FQHCs, RHCs, ASCs, community mental health centers, physicians, therapists, and other health care facilities, entities, practitioners, and clinicians.

[1] 2022 CMS Strategic Framework

[2] CMS Redesigns Accountable Care Organization Model to Provide Better Care for People with Traditional Medicare | CMS

[3] Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model | CMS

[4] Strategic Direction | CMS Innovation Center

[5] CMS Blog: The Future of Medicare Program Integrity - RCPA (paproviders.org)

[6] Prior Authorization and Pre-Claim Review Initiatives | CMS

[7] Center for Program Integrity Request for Information on the Future of Program Integrity (cms.gov) 

[8] Biden calls for minimum staffing requirement in nursing homes : NPR

[9] To Advance Information on Quality of Care, CMS Makes Nursing Home Staffing Data Available | CMS

[10] Nursing Home Staff Turnover and Weekend Staffing Levels | CMS 

[11] CMS Returning to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities | CMS

[12] Unwinding and Returning to Regular Operations after COVID-19 | Medicaid

[13] The Unwinding: Millions Could Lose Medicaid Coverage When the Pandemic Is Declared Over (specialneedsanswers.com)

[14] Biosimilar and Interchangeable Biologics: More Treatment Choices | FDA

[15] 2022-05-26-MLNC | CMS

[16] 2022-05-12-MLNC | CMS

[17] CCI Fact Sheet Behavioral Health (cms.gov)

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