What might be in the works over at the Centers for Medicare and Medicaid Innovation (CMMI)? Are there new pilot models actively in development that will be rolled out this year? Many industry stakeholders, including federal lawmakers, are eager to know what the relatively opaque agency has in store.
Created under the Obama administration, CMMI is charged with piloting, testing and evaluating alternative payment models (APMs)—such as bundled payment models, for example—with the intent of increasing quality and efficiency, while reducing program expenditures under Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).
However, CMMI has been notably quiet in the first two years of the Trump Administration with regards to new payment models. Last January, CMS did launch a new voluntary bundled payment model, Bundled Payments for Care Improvement Advanced, the Administration’s first Advanced APM.
In several speeches to industry groups this past fall, Health and Human Services (HHS) Secretary Alex Azar has indicated that the Trump Administration is exploring new voluntary bundled payments, and even revisiting mandatory bundled payments, which represents a strong about-face in the Trump Administration’s policy about bundled payment initiatives. Azar has even hinted that CMMI will get more involved in addressing social needs, such as food insecurity and housing.
However, the agency has yet to announce any new payment model pilots, leading many healthcare stakeholders to speculate about what’s coming next.
Back in September 2017, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma wrote an op-ed in the Wall Street Journal where she said that the Trump administration would lead CMMI “in a new direction” to give providers more flexibility with new payment models and to increase healthcare competition. Verma said at the time that CMS was analyzing all Innovation Center models “to determine what is working and should continue, and what isn’t and shouldn’t.” The agency also issued an RFI for ideas on how to determine the best path forward for CMMI, to which various healthcare associations responded with comments and suggestions.
Verma has previously voiced skepticism about some CMMI initiatives, including mandatory bundled payment programs.
It was over a year after President Donald Trump took office that Adam Boehler, the former CEO of home-based care startup Landmark Health, was named CMMI Director in April. A month prior, in March, Politico reported that “There’s been a recent exodus of top officials at the CMS Innovation Center, and the installation of a new leader at the office has been on hold because of financial conflicts. The Obamacare-created office, which many Republicans have viewed with suspicion, has so far received minimal attention from administration leaders.”
Republicans lawmakers have had a love-hate relationship with CMMI, insofar as GOP leaders, including former Congressman Tom Price, M.D., who later was appointed HHS Secretary by President Trump, called out CMMI for “overstepping its authority” by proposing mandatory healthcare payment and service delivery models. In September 2017, Republican lawmakers wrote a letter to CMS and were particularly critical of a CMS final rule requiring at least 800 hospitals in 67 geographical regions to participate in a bundled payment model for hip and knee replacements. That model, the Comprehensive Care Joint Replacement (CJR) model, is operated by CMMI. The Trump Administration has since rolled back that model and cancelled a mandatory cardiac bundled payment model, which also would have been operated by CMMI.
However, Azar, who was confirmed as HHS Secretary earlier this year, signaled early on that he diverged from Verma and Price on his views about mandatory bundled payments.
Many healthcare industry stakeholders who support accelerating the transition to value-based care and payment models are eager for CMMI to develop and roll out new voluntary alternative payment models. And others want to see more transparency in the process. Just this week, two Congressional leaders, U.S. Representative Richard Neal (D-MA), chairman of the House Committee on Ways and Means, and Rep. Kevin Brady (R-Texas), ranking member of the committee, sent a letter to Verma calling for greater transparency from CMMI as it develops new delivery and payment models, noting that its process has “historically been opaque to Congress and to stakeholders.”
Further, Reps. Neal and Brady wrote, "Significant policy changes made unilaterally by the executive branch without sufficient transparency could yield unintended negative consequences for beneficiaries and the health care community. We strongly urge the Agency to provide more sunshine in this process."
In a tweet posted Thursday, Anders Gilberg, senior vice president, government affairs for the Medical Group Management Association (MGMA), welcomed the lawmakers’ efforts to encourage more transparency from CMMI and CMS officials. “Medicare payment model development has been both opaque and anemic. Medical practices need new non-mandatory APMS (alternative payment models) in 2019,” Gilberg tweeted.
Many industry stakeholders are anticipating bold moves out of CMMI in the near future. As reported by Healthcare Informatics Editor-in-Chief Mark Hagland, Don Crane, CEO of the Los Angeles-based America’s Physician Groups, recently noted that statements from federal healthcare officials have made it clear that plans are afoot to accelerate the transition from fee-for-service payment to risk-based and value-based reimbursement. Crane, who said he has participated in roundtables with Boehler, further said, “We haven’t seen any pending rules yet, but we need to get ready for some bold moves in Medicare, where they accelerate the movement.”
Last April, CMMI issued an RFI on direct provider contracting (DPC) between payers and primary care or multi-specialty groups to inform potential testing of a DPC model within Medicare fee-for-service and Medicare Advantage programs, and Medicaid. Crane said he anticipated a DPC model coming out of CMMI.
In a keynote speech at the Patient-Centered Primary Care Collaborative Conference this past fall, in early November, Azar indicated that CMS is revisiting mandatory bundled payment models, possibly for radiation oncology and cardiac care. During the speech, he said, “We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology. We’re also actively looking at ways to build on the lessons and successes of the Comprehensive Care for Joint Replacement model.” He added, “We’re not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models.”
Further, Azar said CMMI would launch new primary care payment models before the end of 2018, with the aim of introducing a spectrum of risk for primary care providers, although no new models were announced.
“Before the end of this year, you will see new payment models coming forth from CMMI that will give primary care physicians more flexibility in how they care for their patients, while offering them significant rewards for successfully keeping them healthy and out of the hospital,” he said.
Also, in a speech to the Hatch Foundation for Civility and Solutions later in November, Azar also hinted that CMMI will get more involved in addressing social needs, such as food insecurity and housing.
During the speech, Azar pointed to the Accountable Health Communities model from CMMI, which was announced in 2016 and launched last year. The model incentivizes providers to screen high utilizers for social needs, such as food insecurity or transportation, housing, and utility needs.
“But what if we went beyond connections and referrals? What if we provided solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food? If that sounds like an exciting idea . . . I want you to stay tuned to what CMMI is up to," Azar said in that speech.
Beyond payment models, Jeff Smith, vice president of public policy for the Bethesda, Md.-based AMIA (American Medical Informatics Association) notes there is tremendous opportunity for CMMI to expand its focus and provide innovation support, not simply financial support, to transform care delivery. Reiterating comments AMIA submitted to CMMI’s New Direction RFI in September 2017, Smith said CMMI should be focused on testing new ways to leverage health IT in ways that can’t be done, given the current constraints for billing and documentation.
“There’s no reason that CMMI couldn’t decide to test different kinds of NLP (natural language processing) and sensor-based motion detection technology and figure out how to extract information for billing, for example,” Smith says.
“I think CMMI should tackle workforce and education. Right now, we have just fewer than a few dozen ACGME-accredited Clinical Informatics Fellows programs across the country. These programs are producing the Clinical Informatics leaders of the future, but we need more of them and we need better structural funding,” Smith says. “CMMI could establish a model that looks at the care improvement and cost savings of these programs and begin to develop an evidence base for how institutions who employ such Fellows fare vis-à-vis those who don’t.”