PE R S PE C T IV E
Beyond a Traditional Payer CMSs Role in Improving
Population Health
William J. Kassler, M.D., M.P.H., Naomi Tomoyasu, Ph.D., and Patrick H. Conway, M.D.
T here is an emerging consen-
sus that to improve health as
much as possible, we must adopt
population health strategies ad-
dressing underlying causes of
poor health.1 The term popula-
tion health has been used to
describe both a clinical perspec-
tive focused on delivering care
to groups enrolled in a health
system and a broader perspec-
tive that focuses on the health
of all people in a given geo-
graphic area and emphasizes
multisector approaches and incor-
poration of nonclinical interven-
tions to address social determi-
nants of health.2,3
As a health care payer, the
Centers for Medicare and Medic-
aid Services (CMS) focuses pri-
marily on health care delivery for
our beneficiaries. The agency has,
however, articulated a commit-
ment to improving broader pop-
ulation health through the CMS
Quality Strategy, which aims to
improve the health of the U.S.
population by supporting proven
interventions to address behav-
ioral, social, and environmental
determinants of health in addi-
tion to delivering higher-quality
care.4 This vision reconciles the
clinical and community perspec-
tives on population health by
considering the various popula-
tions to which an individual be-
longs as a series of concentric
circles: a panel of patients in a
practice, patients attributed to a
delivery system, and larger geo-
graphically defined populations.
CMS is working in each of these
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CMSs Role in Improving Population Health
domains to encourage incremen-
tal progress toward population
health.
For medical practices, which
are structured around individual,
face-to-face encounters, pursu-
ing a population-based approach
means considering what happens
between visits; using patient reg-
istries and other tools to improve
the use of preventive care ser-
vices; addressing health dispari-
ties by considering social, eco-
nomic, and cultural factors; and
referring patients to a wider
range of community services.
Through our Innovation Center,
CMS is testing various approach-
es for medical practices, includ-
ing methods for linking practices
and patients to social support
services and care management
payments for nonface-to-face
services to support outreach and
coordination. CMS Health Care
Innovation Awards (HCIAs) are
being used to facilitate referrals
between medical homes and com-
munity resources and to assign
community health workers to as-
sist patients with translation, ap-
pointment scheduling, referrals,
and transportation.
At the next level, delivery sys-
tems can make progress toward
population health by assessing
community health needs and col-
laborating with other organiza-
tions to support nonmedical ser-
vices that improve health but are
delivered in community settings.5
CMS has several payment models
involving outcomes-based, global,
or risk-based payments that pro-
vide incentives for delivery sys-
tems to invest in efforts to im-
prove health and reduce costs.
Although accountable care orga-
nizations (ACOs) must initially
invest in internal systems for co-
ordinating care, mature ACOs
are exploring opportunities to
incorporate nonclinical members
into care teams to help high-risk
patients connect to practices and
address social and community-
based barriers to care.
For health plans, Medicaid
and Medicare contracts afford
greater flexibility than fee-for-
service arrangements in paying
for population-based services.
Some managed-care organiza-
tions, for instance, cover bicycle
helmets and car seats or enroll-
ees participation in the YMCAs
Diabetes Prevention Program or
the March of Dimes Baby and Me:
Tobacco Free program. Other or-
ganizations, through sponsor-
ships, grants, and partnerships,
are investing in housing support,
employment initiatives, literacy
programs, and services for over-
coming food insecurity.
Medicaid, a partnership be-
tween states and CMS, has his-
torically paid for nonmedical
support services, such as trans-
portation, health education, coun-
seling, and community-based sup-
port intended to address some
underlying causes of poor health.
Waivers and demonstration proj-
ects give states opportunities to
expand benefits and incorporate
more upstream strategies. For
example, under its waiver, Ver-
109
PERS PE C T IV E
mont covers day care for infants
of substance-abusing mothers,
providing an enriched environ-
ment for promoting healthy child
development.
Our State Innovation Models
(SIM) Initiative requires partici-
pating states to use their regula-
tory, payment, and policy author-
ity to improve their populations
health. Oregon has invested SIM
funds in building public health
capacity for conducting commu-
nity health assessments, tracking
progress on population health
goals, and providing timely in-
formation to local public health
and community-based organiza-
tions and hospitals. Oregon has
also used SIM funds to imple-
ment evidence-based interven-
tions for improving population
health, such as overdose-preven-
tion efforts, tobacco-control ac-
tivities, and interventions promot-
ing maternal and child health, in
both health care and community
settings.
Minnesota will create Account-
able Communities for Health,
giving ACOs shared account-
ability for population health and
providing them incentives to in-
tegrate community services and
organizations. States receiving
second-round SIM awards will
be required to develop and im-
plement population health im-
provement plans that address
core population health metrics,
focus on the entire population,
and target high-risk groups and
those with poorer health out-
comes.
There are limits to CMSs stat-
utory authority to fund services
provided to people other than
Medicare or Medicaid beneficia-
ries, but the agency can leverage
its influence beyond the payment
of claims. Whereas our approach-
110
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CMSs Role in Improving Population Health
es for providers focus on enrolled
or attributed populations, SIM
seeks to affect broader popula-
tions. Other CMS-funded mod-
els, such as Pioneer ACOs and
the Comprehensive Primary Care
Initiative, explicitly require multi-
payer engagement to amplify our
programs effects.
We are also funding infra-
structure projects designed for
Medicaid and Medicare recipients
but with collateral benefit for
other populations. HCIAs are be-
ing used to build asthma regis-
tries, community-resource data-
bases, and referral mechanisms
for community services that are
available to all local residents.
HCIA-funded community-based
programs for diabetes education
are open to the uninsured as well
as CMS beneficiaries, and a door-
to-door immunization-outreach
campaign being conducted in a
rural Hispanic community is
similarly not limited to benefi-
ciaries.
Some projects are testing ap-
proaches that address upstream
determinants of health. In solic-
iting second-round HCIA appli-
cations, we called for models
that aim to improve the health of
populations, defined geographi-
cally, clinically, or socioeconomi-
cally. A common approach is to
employ community health work-
ers drawn from the populations
being targeted. Such workers can
provide education about high-
risk behaviors and self-manage-
ment of chronic conditions, con-
duct home-based environmental
assessments for lead and asthma
triggers, and provide help in ap-
plying for housing, food assis-
tance, and other social services.
One HCIA project provides sup-
plies for environmental interven-
tions to reduce asthma triggers,
n engl j med 372;2nejm.orgjanuary 8, 2015
The New England Journal of Medicine
and a school-based clinic is seek-
ing to assess and address food
insecurity and traumatic stress
by linking those risk factors to
school absenteeism and perfor-
mance.
CMS faces several challenges
in catalyzing improvement in
total population health. Though
the agency has authority to test
new approaches, evaluation of
their effectiveness is ongoing,
and questions remain about how
best to scale up successful mod-
els. Because of the longer time
horizon needed for population-
based interventions than for clin-
ical interventions, current actu-
arial methods used to evaluate
return on investment may under-
estimate potential savings. CMS
will not be able to cover the full
range of needed population
health services, particularly those
that are more removed from the
clinical care of beneficiaries. The
agency can address this limita-
tion by aligning our incentives
with those of private-sector pay-
ers, supporting infrastructure
building, and collaborating with
public health and social pro-
grams.
Population health improve-
ment efforts are also hampered
by a lack of agreement regarding
the specific population-based ac-
tivities that fall within health
care providers scope of practice.
Because so many factors lie out-
side clinicians control, we need
to understand what factors the
health care system can reason-
ably be expected to act on, given
professionals training, infrastruc-
ture, and scope of practice; we
also need to determine the ap-
propriate levels of health system
accountability for population
health outcomes. We believe that
lessons learned from the Innova-
PE R S PE C T IV E CMSs Role in Improving Population Health

tion Center models will be par-
ticularly valuable in determining
which services CMS can support
and which will need to be pur-
sued through partnerships.
Although many investments
that will be required to amelio-
rate social determinants of poor
health must come from outside
the delivery system, we see CMS
as playing a catalytic role. By em-
bedding population-based strat-
egies in our programs and poli-
cies, CMS can help drive
transformation that aligns health
care systems with public health
and social service systems and
thereby accelerate progress to-
ward improved health for our
whole country.
The views expressed in this article are
those of the authors and do not necessarily
represent the views or policies of the Cen-
ters for Medicare and Medicaid Services.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Centers for Medicare and Medic-
aid Services, Boston (W.J.K.) and Baltimore
(N.T., P.H.C.); and the Cincinnati Childrens
Hospital Medical Center, Cincinnati (P.H.C.).
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health? Am J Public Health 2003;93:380-3.
3. Jacobson DM, Teutsch S. An environ-
mental scan of integrated approaches for
defining and measuring total population
health by the clinical care system, the gov-
ernment public health system, and stake-
holder organizations (http://www.improving
populationhealth.org/PopHealthPhaseII
CommissionedPaper.pdf).
4. CMS quality strategy, 2013beyond (https://
www.cms.gov/Medicare/Quality-Initiatives
-Patient-Assessment-Instruments/Quality
InitiativesGenInfo/Downloads/CMS-Quality
-Strategy.pdf).
5. Hacker K, Walker DK. Achieving popula-
tion health in accountable care organiza-
tions. Am J Public Health 2013;103:1163-7.
DOI: 10.1056/NEJMp1406838
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