Moving AHEAD by Overcoming Potential Challenges to Healthcare Transformation

Healthcare access and costs in the U.S. continue to move in opposite directions—access is declining while costs keep rising. Americans need innovative solutions that tackle both challenges at the same time. The Centers for Medicare & Medicaid Services (CMS) Innovation Center’s Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model is one initiative aiming to address these challenges by curbing healthcare costs, improving population health, and promoting healthier living. Although promising, like all models, implementation across 6 participating states will create challenges that state leaders will need to meet head-on to ensure the AHEAD Model is successful.

Westat’s Lauren Mercincavage, MHS, and Brandon Hesgrove, PhD, Principal Research Associates for Behavioral Health and Health Policy, and Dominick Esposito, PhD, a Vice President for Health, discuss the AHEAD Model’s implementation challenges and potential strategies for success.

Q. This CMS Innovation Center model brings together healthcare providers and community organizations in 6 states. What are the biggest challenges to AHEAD implementation?

A. Lauren Mercincavage: Because AHEAD is a decade-long, total cost of care (TCOC) model, it will invariably meet with headwinds and tailwinds. For instance, state healthcare policy leadership will change over time, which means that priorities for healthcare transformation, chronic disease management, and prevention may also shift. Implementation success will hinge on ongoing support from state agency leaders for policy changes implemented by AHEAD.

Brandon Hesgrove: Agreed. And, because the AHEAD Model will impact multiple levels of the health system to curb healthcare costs and improve population health, bringing multiple actors to the table to ensure success will be necessary. States will have to find a way to efficiently manage AHEAD’s many moving parts: state implementation, hospital and primary care provider participation, payer alignment, and data infrastructure.

Dominick Esposito: This will all happen while states are also fulfilling the requirements of existing value-based initiatives or other quality improvement programs that require ongoing management and coordination. At the outset, states must be thoughtful about the design of AHEAD within their specific context to complement existing programs and support ongoing priorities. 

Q. Who might stand to benefit as a result of the implementation of the AHEAD Model?

A. Lauren Mercincavage: There’s a real opportunity for improvement at all levels of the healthcare system. Patients can benefit because of AHEAD’s focus on population health and healthier living. The model’s focus on healthcare policy redesign has the potential to bring greater access to care for people previously unable to obtain it. For example, AHEAD’s emphasis on investment in primary care and the integration of behavioral health could improve access to care for patients who need it the most.

Brandon Hesgrove: Plus, some AHEAD states may choose to relax the scope of practice restrictions for providers like physician assistants or nurse practitioners, offering more options to patients who live in areas of the country where access is limited, such as many rural areas where it is difficult to recruit providers. This approach is consistent with several CMS Innovation Center initiatives to enhance access and quality in primary care and behavioral health settings.

Dominick Esposito: Outside of patients, healthcare providers who can successfully navigate this new value-based model also have an opportunity to win. For instance, health systems that refine their approach to whole-person care can achieve success over time by encouraging and promoting greater use of primary care, shifting unnecessary care in hospital settings to outpatient settings.

Q. You mentioned the concerns related to state health leadership shifting over time. How would changes to state leadership impact AHEAD’s implementation?

A. Lauren Mercincavage: When state health leaders change, there’s often a transition period where priorities may shift. It will be essential that new leaders in participating states have access to data and insights on AHEAD early in their tenures to ensure programs persist. Because AHEAD is designed to improve healthcare efficiency through value-based care improvements, it is likely that state leaders will see the benefits of the model over time and sustain it throughout the planned decade-long period.

Q. AHEAD is designed to promote population health across communities, from large systems to rural clinics. How can states tailor their strategies to different local needs?

A. Brandon Hesgrove: Each state will need to identify which geographic areas require more support than others. For example, providers in large health systems will likely need different support than rural or independent providers. So, expertise in tailoring support strategies is essential to ensure the CMS Innovation Center’s objective to promote greater choice and competition is met. For states, this might mean expanding access to telehealth services for patients in rural areas or encouraging site neutrality for care. States will also have the option to develop a geographically based accountable care organization (referred to as Geo AHEAD) to spur greater coordination across providers, reducing costs and improving quality. The strategies states choose will have a bearing on the extent that independent and rural healthcare providers can fully participate and succeed under this model.

Q. What are some of the risks if states do not effectively coordinate AHEAD’s many moving parts?

A. Lauren Mercincavage: Ineffective coordination could result in challenges for some healthcare providers and certainly for patients. For example, if hospitals cannot determine how to best collaborate with primary care providers, one or both could lose out. Patients could be negatively affected if coordination across different levels of the healthcare system fails.

Q. How will CMS determine states’ progress in implementing AHEAD and assess if, and how, the model is effective?

A. Brandon Hesgrove: Ongoing assessments of states’ progress in meeting primary model objectives will be vital. This will require a steady stream of data from existing and new data sources to support timely decision-making and understand what’s working and not working in the field.

Q. How will AHEAD impact and benefit the everyday lives of Americans?

A. Dominick Esposito: So, one potential positive scenario for AHEAD is that primary care providers will spend more time with patients on care coordination, inquiring about their housing, transportation, and food access, as well as their medical issues. Hospitals that operate within a fixed budget will focus on maintaining patients’ health and coordinating with other providers rather than just treating patients at each emergency admission. As a result of AHEAD, we should see healthcare costs decrease, services and resources expand, and health outcomes improve, not only in urban areas but also in rural areas or other communities. There is real promise for this to be a win for patients, providers, and states.