Where Will CMMI Go From Here? CMS Wants Your Input

Thursday, September 28, 2017 | Larry Sobal

 

Recent attention on health care has been focused on the Republican attempts to meet the September 30^th deadline for the Senate to pass some type of Affordable Care Act (ACA) repeal and replace legislation. Alas, opposition to the most recent attempt (the Graham-Cassidy proposal) came from Senators including John McCain and Susan Collins, and has signaled the end of GOP-only legislation, at least for now.

What hasn’t gotten as much press is something all physician and hospital leaders should pay close attention to; there are comments coming from the White House hinting that changes to CMS' Center For Medicare & Medicaid Innovation (CMMI) may be in the works. In my opinion, changing the CMMI has the potential to be as interesting, far-reaching and polarizing as the ACA repeal and replace political stalemate, if not for the American population then for health care industry professionals. And in case you thought that this could be a much needed bipartisan conversation, Democrats including Richard Neal (D-MA) and Frank Pallone (D-NJ) already have issued a press release strongly voicing their opposition to suggested CMMI changes.

If you aren’t well versed on the CMMI (aka Innovation Center) and its role, let’s start with a synopsis. The genesis of CMMI was the Affordable Care Act. By passing the ACA, Congress created the Innovation Center for the purpose of testing “innovative payment and service delivery models to reduce program expenditures . . . while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.”

The ACA suggests, but does not require, that the Innovation Center explore at least 18 priorities, including multi-payer initiatives. The Innovation Center's leadership has historically professed that it will pursue initiatives to address the Triple Aim of health care: (1) improve the individual experience of care; (2) improve the health of populations; and (3) reduce per capita costs of care for populations. The ACA also appropriated $10 billion for the Innovation Center every 10 years, into perpetuity. Although $10 billion per decade represents a major spending commitment, keep in mind it is only about 0.1 percent of Medicare and Medicaid spending—far less than most organizations commit to research and development.

Just some of the many programs that have been launched by the CMMI include:

• Comprehensive Primary Care Plus (CPC+)
• Comprehensive End Stage Renal Disease (ESRD) initiative
• Medicare Bundled Payment models including Bundled Payments for Care Initiatives (BPCI) and the Surgical Hip and Femur Fracture Treatment (SHFFT) Model
• Maryland All-Payer Model
• Million Hearts Cardiovascular Disease Reduction Model
• Oncology Care Model
• Pioneer ACO

And let’s not forget that the Innovation Center also plays a critical role in implementing the Quality Payment Program (QPP), which Congress created as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to replace Medicare’s Sustainable Growth Rate formula to pay for physicians’ and other providers’ services.

Aside from the annual hospital and physician fee schedules, most of what Medicare has done since the ACA was passed in 2010 that positively or negatively impacts hospitals has been an output of CMMI. Hence, my earlier statement that the future direction of CMMI is something that all health care leaders should be paying attention to.

CMS is accepting comments until November 20, 2017 and I strongly encourage everyone to take this opportunity to share your views.

So where is CMMI heading?  In an op-ed in The Wall Street Journal last week, Seema Verma, administrator for CMS, said the Trump Administration plans to lead the Center for Medicare and Medicaid Innovation “in a new direction” to give providers more flexibility with new payment models and to increase health care competition. Does that mean anything or is it just political gobbledygook? I think this is real change and my opinion is that we are seeing a kinder, gentler CMS. That’s good news, but it’s too early to tell for sure.

What we’ve seen so far is that Seema Verma and HHS Secretary Dr. Tom Price are canceling or scaling back an array of Obama-era programs that were aimed at encouraging doctors and hospitals to more quickly move away from traditional, fee-for-service medicine. Specifically I am talking about last month’s announcement to cancel the mandatory bundled payment programs that would have paid certain hospitals a lump sum for all of the care associated with heart attacks, bypass surgeries, and some hip and femur fractures, including the initial visit, the surgery, and follow-up care. This new CMS leadership is also canceling a similar program that targeted cardiac rehabilitation, as well as proposing to drastically reduce the number of hospitals that have to participate in a separate program already underway that offers similar lump payments for hip and knee replacements.

That move should have surprised no one since when Dr. Price still served as a Congressman from Georgia, he was one of 200 federal lawmakers who sent a letter to Andy Slavitt, then acting administrator for CMS, calling out CMMI for overstepping its authority by proposing mandatory health care payment and service delivery models. In the letter, those legislators stated that the proposals would negatively impact patients. Furthermore, Verma, during her first Senate confirmation hearing back in February, also voiced similar thoughts about mandatory bundled payment programs. 

Now Price and Verma are asking for input on where CMMI should go next through a Request for Information (RFI). The RFI online submission form to provide comments can be found here.

The request asks for input on eight focus areas: increased participation in Advanced Alternative Payment Models, consumer-directed care and market-based innovation models, physician specialty models, prescription drug models, Medicare Advantage innovation models, state-based and local innovation, mental and behavioral health models and program integrity. The request focuses on market competition and provider choice, but also notes the importance of patient-centered care.

The public can submit comments by email to [email protected]. CMS is accepting comments until November 20, 2017 and I strongly encourage everyone to take this opportunity to share your views.

What I plan to submit will include some of the following suggestions:

• Release a new and improved voluntary BPCI Advanced Version 2.0 to begin sometime in 2018 with enough lead time to be a realistic option.
• Change the Quality Payment Program to ease participation and have more ways and options for physicians to qualify for the Advanced Alternative Payment Model option.
• I’d like to see greater than one-half percent fee increases for the first five years of MIPS, which then reverts to zero thereafter. Furthermore, rather than have MIPS bonuses predicated (to some degree) on the performance of other physicians, if a group of physicians performs well enough they should earn a bonus regardless of how other physicians perform at that level.
• Offer broad relief from anti-kickback and fraud and abuse laws when physicians and hospitals work together in Advanced Alternative Payment Models to stimulate collaboration and innovation without fear of violating Stark.
• Promote and allow individual states to experiment with their own versions of health reform, not just in Medicaid, but for Medicare and potentially all payers.
• The legislation that created MACRA suggested quarterly feedback to physicians. Currently, the annual (and extremely confusing) QRUR is the primary source. Initiate an effective quarterly report.
• Fix the currently flawed patient-to-physician attribution methodology used in CMS reporting. The attribution process is problematic since it has the effect of holding physicians accountable for the cost and quality of care they may not have predominantly provided or influenced.

Since CMMI does have the latitude to make many changes through experimental models, I hope the approach going forward recognizes that we are still in the infant stages of learning what does or doesn’t work in terms of actually accomplishing the Triple Aim and creating “value.” More importantly, I trust that careful consideration is given to how any changes, even voluntary programs, are impacting our physicians and caregivers through a refocus on the Quadruple Aim with an emphasis on reducing administrative burdens. 

 

Please take the time to respond to the RFI. What do you plan to suggest to CMS?

 

Illustration: Lee Sauer

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Larry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at www.medaxiom.com.

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