Revolutionizing CMS Programs: The Role of Digital Health in Medicare and Medicaid

Welcome to Architect Health’s The Front Door Newsletter! In this newsletter, Architect Health’s Co-founder & CEO, Sohum Shah, interviews healthcare executives, founders, and experts on healthcare innovation, digital health, and preventative care. The goal is to identify pain points in these spaces and paint visions on how to address them, inspiring decision makers at traditional healthcare organizations.

Today’s momentous tenth interview features former health plan executive and second-time senior leader at the Centers for Medicare & Medicaid Services, Jonathan Blum. Jon currently serves as the Principal Deputy Administrator and Chief Operating Officer of the CMS and discusses the evolution of digital health across the programs he oversees.

Interview Key Takeaways:

• Reimagine Healthcare with Consumer Focus: CMS is working to simplify healthcare navigation by ensuring that coverage transitions are smooth, with minimal friction for patients as they move through different stages of life.

• Leverage Digital Health: Digital health needs stronger integration into care delivery. CMS is actively working to define patient rights to telehealth and expand access to virtual care services.

• Simplify Care Coordination: CMS is pushing for clearer accountability among health systems and digital solutions, ensuring patients don’t fall through the cracks due to fragmented care efforts.

• Drive Health Equity Investments: CMS is incentivizing health plans to invest in underserved regions, sending a clear message to prioritize stronger healthcare services where they are needed most.

• Raise Medicare Advantage Value: CMS is committed to enhancing Medicare Advantage, ensuring these plans provide truly value-added services like vision and dental while improving patient experiences.

Before we dive into the article: Architect Health is hosting a Healthcare Hackathon in Chicago on November 7th alongside Drive Capital, J.P. Morgan, and Cofactor AI. If you’re a healthcare leader interested in joining, please sign up here.

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In this dual role, Jon oversees CMS’s program policy planning and implementation and day-to-day operations of the entire agency. CMS’s programs provide health coverage to more than 150 million individuals, spending more than $1.7 trillion in annual benefits with an annual operating budget of more than $7 billion.

This is Jon’s second time serving in a senior leadership position at CMS. He previously served as the Deputy Administrator and Director of the Center of Medicare from 2009 – 2014, leading the agency’s Medicare payment and delivery reform strategies and the policy and program management of the Medicare program.

Jon has more than 25 years of public- and private-sector experience working in health care policy and administration. In addition to his positions at CMS, he has worked as a strategy and management consultant, an Executive Vice President for Medical Affairs at CareFirst BlueCross BlueShield, professional staff at the Senate Finance Committee, and a program analyst at the Office of Budget and Management.

Prior to joining CMS, Jon served on several nonprofit boards with missions to improve access and equity to health care and health coverage, including Mary's Center, a Federally Qualified Health Center; the Primary Care Coalition of Montgomery County; and the Medicare Rights Center.

Jon earned a Master of Public Policy from the Kennedy School of Government at Harvard University and a Bachelor of Arts from the University of Pennsylvania.

Ideal Healthcare Experience

Sohum: What is your ideal vision for how healthcare should be consumed by the patient? How can incumbent healthcare organizations, including CMS and policymakers, work together to achieve that?

Jon: For CMS, the North Star is that no matter what your life circumstance is, no matter what your coverage is, we want the overall care system to be seamless to consumers. Because someone changes their health insurance plan, they shouldn't necessarily have to change their doctor or their care system.

CMS now covers nearly half the population through Medicare, Medicaid, and Marketplace programs. This creates a phenomenal opportunity to think differently about how people navigate coverage throughout their lives. Our goal is that as people navigate various life events, their care system remains stable and strong, and their access to care is far simpler.

Part of the goal, too, is to reduce friction in the system, and to improve care coordination that is often so complex to organize. The aim is for it to become far easier over time. This requires CMS, as a payer and a very strong overseer to our healthcare system, to think differently. We used to think about these three programs in silos, but now the imperative is to think more system-wide.

Digital Health Evolution

Sohum: How has your view of digital health, like telehealth apps and virtual-first care, changed over time? What does the future hold in store?

Jon: Before the COVID-19 pandemic, CMS's stance was that digital health and telehealth could be abused, hard to price, hard to deliver, hard to scope, and had serious risks for overuse. But the pandemic taught CMS that we must think differently.

Telehealth kept the healthcare system operating during the pandemic due to flexibilities triggered by CMS. However, we need now need to think about what the consumer should receive, what the experience should be, and what kind of guaranteed right they should have to telehealth services.

Today, if providers choose to deliver services through telehealth, they have more means to bill and reimburse. But that's not the same as saying everyone covered by a CMS program has the right to receive telehealth services.

CMS and Digital Health

Sohum: From the health governance lens, how does CMS view digital health more broadly? How can digital health solutions work with CMS to support home-based care initiatives and value-based care models?

Jon: We're still learning, to be honest. The pandemic really turbo-boosted how we see the world going forward. One area we need to build much stronger consensus around is how we think about the organization of care.

Public policy today is often too silent on who is really accountable for the overall care experience, the organizations of care coordination programs, and the organization of digital health solutions that could best serve the patient. We have a lot of care innovations that we're testing to get to that answer, but I don't think today that public policy has come to a solid conclusion.

The net result is that the consumer today is often bombarded by different entities in the healthcare system saying that they're here to help coordinate their care. Often, patients covered by CMS programs have a health plan—sometimes multiple plans, a primary care provider participating in an ACO, a discharging surgical practice, taking complex medications, often dually eligible for Medicare and state Medicaid coverage. They have multiple people coming at them saying they're here to coordinate their care, yet no one's really coordinating that care, and the patient/consumers feel fatigued and then disengage in their care plan.

Quality Rating Systems

Sohum: Are there any initiatives from CMS to regulate, monitor, and/or rate digital health solutions on quality?

Jon: Not yet, but I think that's really a question for the future. We're spending more time understanding what quality measures the consumer cares about. In the new Center for Innovation Models that we're testing, we're building measure sets that are much more consumer-oriented, beneficiary-oriented.

For digital health, we need to consider what a patient wants to receive. Do they want to be home more? Could that be a future quality measure? I think that's where the vanguard will be going forward - a simpler measure set, a more common measure set that spans programs and care settings, and a much more focused measure set that tries to draw out and respond to what consumers and their caregivers want from their care system.

Health Equity Index

Sohum: How do you see CMS's health equity index incentivizing health plans to make meaningful improvements in health equity? What role could virtual care solutions play in promoting that?

Jon: We're trying to signal through our reimbursement systems that health plans, for example, need to invest in much stronger services in parts of the country that don't have a strong base. We're changing how we think about the incentive structure.

It's not yet significant dollars that are shifting around the country, but it is sending the signal, the incentive to a health plan, to a health system to invest in parts of the country that are under-resourced and not able to provide full access to care.

Point-solution Fatigue

Sohum: What are CMS's perspectives on point solution fatigue and choice overload bias? Are there any approaches CMS has been taking to address it and coordinate care?

Jon: Part of the solution is proceeding to think through how we simplify our goal statements and build a stronger consensus of how we collectively define accountable care. CMS programs are building to that vision, which means that the care solutions we implement, or test respond to those more simplified goals. A more unified and accepted vision will reduce the fatigue.

We need to build consensus on what is the role of the health plan, the health system, the primary care practice, the ACO medical home, and then begin to organize the care experience for those roles and responsibilities.

Medicaid Program Changes

Sohum: What can the broader health tech ecosystem do to support CMS goals of better access to high-quality, affordable care for Medicaid beneficiaries?

Jon: We are now in the final stages of working with states to complete required redeterminations of Medicaid eligibility that were suspended during the COVID-19 pandemic. What we'll see once we come out of this transition is that more people will be covered by the Medicaid program and other sources, than before the pandemic.

This creates an imperative that Medicaid programs are no longer deemed as temporary programs. We must ensure that people who receive Medicaid coverage have high-quality care and access to services. For example, we now have new rules in place that require health plans to demonstrate they have far superior provider networks.

One of the silver linings during the pandemic and the redetermination process is that we have stronger eligibility systems in place today than before to help people connect to new sources of coverage that will reduce unnecessary churn in enrollment and hardship for those eligible for Medicaid. State eligibility systems needs are not where they need to be, but they are better today than it was before the pandemic due to a lot of hard work by CMS and our state partners.

Structural Barriers to Care

Sohum: What responsibilities do health plans, traditional care providers, digital health providers, and CMS have in removing structural barriers to care?

Jon: The lack of coordination between federal, state, and local health policies often interferes in producing simple, coordinated coverage solutions, particularly for those most dependent on CMS programs. For example, for those dually eligible beneficiaries who are covered by both Medicare and Medicaid, they too often have a separate plan for Medicare benefits and a separate plan for their state Medicaid benefits. The vision we want to promote going forward is a much more unified care and coverage experience that reduces unnecessary waste, burden and confusion for both the beneficiaries of our programs and their care providers.

If we really want to think through how to innovate programs, how to close gaps in care, how to close care access gaps, it goes to that central point of defining and building consensus for who is accountable for the full array of beneficiaries’ healthcare experiences.

Medicare Advantage Growth

Sohum: From CMS's lens, what are the underlying trends causing the slowing growth of Medicare Advantage? Is this something to be concerned about?

Jon: We don't manage the programs to hit a particular growth target. Our goal is to ensure that if somebody wants to choose traditional Medicare or if they want to receive their benefits through a private plan, they have the best possible experience no matter the choice.

Today, MA plans are paid more on average for enrollees compared to traditional Medicare. We must ask, well, is the value better for that higher payment. Today we don't see much difference in the overall quality metrics. We don't necessarily see patient satisfaction be higher for those choosing MA. We hear a lot of complaints from both patients and providers regarding the friction that can be created by private plans.

The strategic vision we have is that for those who choose the MA program, the value is high, the experience is high. For those who are giving up the right to see any physician covered by the Medicare program, there's something truly value-added by the providers, like high-quality hearing, vision, dental benefits - things not covered by traditional Medicare. There's a better care experience, better quality outcomes. We need to and will do more to ensure this value is created and demonstrated.

What’s Next for 2024?

Sohum: What are you most looking forward to for the rest of 2024? What are some changes or trends in healthcare that you're most excited to witness?

Jon: Our teams are, for the first time in the history of the Medicare program, negotiating prices for drugs covered by the Medicare program. CMS just issued new regulations to create staffing standards for nursing homes. We've got exciting and new programs going into place to change how we think about program integrity, care innovation and quality programs.

There's so much going on at CMS right now, and I couldn't be prouder of our teams and the progress we've made during the last couple of years. It would take us many more hours to talk about the full breadth of our work right now.

Architect Health is a digital health aggregator, navigator, and vendor manager that makes it easy for health plans and their members to access virtual-first care solutions. Architect optimizes health plan RFP processes in a consolidated and comprehensive platform, reducing admin burden and costs. This helps health plans realize digital health cost savings opportunities - up to a 7x ROI. Architect's Digital Health Quality Index has vetted and scored thousands of telehealth solutions on efficacy, company reliability, and health equity. Co-founders Sohum Shah and Sidd Hariharan have deep expertise working with health plans and have built care management programs and aligned technology for Humana and BlueCross BlueShield. Architect Health is backed by Drive Capital, Entrepreneurs Roundtable Accelerator (ERA), Cherrystone Angel Group, Plug and Play Ventures, Service Provider Capital, and strategic advisors.

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