Top challenges facing the new CMS administrator

With each new administration, the head of the Centers for Medicare & Medicaid Services (CMS) faces challenges left behind from legacy teams and processes. In 2021, however, the challenges are that much greater due to the COVID-19 pandemic, dramatic policy shifts made by the previous administration, and the coming Medicare insolvency threat.

Chiquita Brooks-LaSure has been nominated as the new CMS administrator under President Biden - once confirmed, there are a few key challenges that will likely take top priority for her and her team to establish a forward-looking agency while addressing a legacy of challenges and pressures.

1. Imminent threat of Medicare insolvency

The most immediate challenge, especially in the wake of the COVID-19 pandemic, will be the imminent threat of Medicare insolvency. In September 2020, the Congressional Budget Office (CBO) issued a worrisome outlook on the solvency of the Hospital Insurance (HI) Trust Fund, forecasting the HI fund would become insolvent by 2024, a full two years sooner than originally forecast by an April Medicare Trustees report.

The reasons for the drastic change include the continued enrollment of the baby boomers and reduced Medicare payroll taxes due to the pandemic's impact on the economy. The new CMS administrator can target a few key, tactical areas to help restore longer-term solvency.

Targeting high-cost care

A number of health conditions carry a large weight on the Medicare budget, such as sepsis, clostridioides difficile (C.diff), and other healthcare-associated infections. In 2020, Health and Human Services reported a 40% increase in Medicare beneficiaries hospitalized with sepsis from 2012 to 2018, and the condition cost more than $41.8B in 2018 alone. By identifying solutions to mitigate these conditions – especially preventable ones – CMS can help relieve long-term Medicare costs.

Accelerating value-based care

The CMS can accelerate technology and data-based innovations to increase value-based reimbursement adoption and promote evidence-based care through groups like Accountable Care Organizations (ACOs) to avoid unnecessary and wasteful medical procedures and testing. Medical communities could receive incentives by improved outcome reporting and creating innovation in processes or technology.

Additionally, focusing on digital models for more effective opioid stewardship and clinical surveillance for hospitals can help administrators understand how to target assistance and provide additional resources and incentives to mitigating long-term costs.

2. Accelerating CMS innovation and advocacy momentum

CMS has historically been a leader in promoting healthcare data innovation and the new administrator has an opportunity to reinvigorate that charge. One way is by going beyond the information blocking rules and transform data practices to improve reporting, access, exchange, and use of electronic health information (EHI). Another opportunity is continuing to support and develop artificial intelligence (AI) initiatives that enable large-scale data interoperability, modeling, and improved population health analytics. By encouraging interoperability by setting data sharing rules and regulations, CMS can encourage hospitals to adopt streamlined approaches to health data and analytics to identify opportunities for improved patient care and cost reduction.

3. Fragmented approaches to health disparities and inequities

The COVID-19 pandemic has shone a glaring spotlight on systemic health inequalities and the new administrator will need to take a cohesive, multi-pronged approach to address the big picture. Advanced data science can target social determinants of health (SDoH) to address inequities, especially by unifying and mobilizing vast troves of data collected during the pandemic. Data science can also be utilized in understanding health behavior changes throughout the population, providing insight into how best to get patients back into their doctor's offices for care that has been postponed by the pandemic.

Another challenge to health disparities is the ability to access Medicaid, especially during a time of unreliable employment, and the extensive work verification paperwork burdening enrollees most in need. By proactively dismantling work verification requirements for Medicaid, enrollees can avoid the risk of losing healthcare in the near-term during a pandemic. These verifications could be determined by states, and some financial incentives might be attractive to states to provide their own package and requirements.

4. Supporting government health programs

The CMS administrator will also likely be leading the charge for the Biden administration in shoring up and building upon the Affordable Care Act and related health exchanges, waivers, and subsidies for states. This will be especially urgent as new enrollments are expected from February to May 2021 through the Special Enrollment Period declared through executive order, which has already seen more than 200,000 new enrollments through early March.

Additionally, while final details are still being confirmed, CMS will play a notable role in the American Rescue Plan (ARP), the Biden administration’s wide-reaching $1.9 trillion economic stimulus package. The AARP calls for expanding Medicaid which would be achieved with incentives for states to expand their Medicaid rolls.