On September 20, 2017, the Centers for Medicare and Medicaid Services ("CMS") released an informal request for information ("RFI") seeking stakeholder feedback on the future direction of the Center for Medicare and Medicaid Innovation ("CMMI"). 1 The announcement is the latest in a series of moves by the Trump Administration signaling a shift in CMMI's role.
The RFI presents an excellent opportunity for stakeholders — including health systems, hospitals, physician and practitioner organizations, suppliers, payers, and private sector innovators — to share their diverse perspectives on the Administration's approach to value-based care and inform future CMMI initiatives and grant making. Comments are due to CMS by November 20, 2017.
Background
The Patient Protection and Affordable Care Act ("ACA") appropriated $10 billion through 2019 — and $10 billion for each 10-year period thereafter — to support CMMI's development and testing of innovative payment and service delivery models that have the potential to improve the quality of care and reduce Medicare, Medicaid, and Children's Health Insurance Program spending. Under the previous Administration, CMMI committed much of its 10-year appropriation to innovation grants and the development of payment and delivery models aimed at shifting providers from a volume-driven, fee-for-service care model to a "value-based" model. Some of CMMI's most popular demonstration programs are built on Medicare's existing fee-for-service infrastructure but employ risk sharing and other incentives through accountable care organizations, bundled payment programs, and comprehensive primary care models, among others, to improve outcomes and quality while reducing costs.
Although stakeholders have generally supported testing innovative payment and care delivery approaches, CMMI's rapid expansion of new, often complex models, including some that mandated provider participation, led some to question whether CMMI's authority should be curtailed. Among the most critical of CMMI's work, particularly with regard to mandatory bundled payment models, was then-Congressman Tom Price (R-GA), who served as Secretary of Health and Human Services ("HHS") in the Trump Administration through September 29, 2017. In September 2016, Dr. Price led a group of 179 House Republicans in signing a letter directing CMMI to cease all mandatory initiatives, which the group believed exceeded the agency's authority.
Trump Administration Seeking New Direction for CMMI
As Secretary of HHS, Dr. Price responded to stakeholder calls to ease the transition to value-based care and limit the reach of CMMI's mandatory payment models. Seema Verma, who oversees value-based programs as CMS Administrator and is viewed as a potential successor to Secretary Price, has also supported these shifts in policy. Earlier this summer, CMS proposed significant changes to two value-based payment programs that suggested a new direction for the Administration. In June, CMS released a proposed rule for year two of the Quality Payment Program that sought to slow its implementation and further accommodate small physician practices. 2
In August, after repeatedly delaying several mandatory bundled payment models 3, CMS ultimately proposed to scale back the Comprehensive Care for Joint Replacement ("CJR") Model, a bundled payment program for hip and knee replacement implemented by the Obama Administration, and eliminate the Episode Payment Models ("EPM") and Cardiac Rehabilitation ("CR") Incentive Payment Model scheduled to begin on January 1, 2018. 4
As Congress and the Administration shift their legislative focus to other priorities, the Administration is likely to take executive action to implement portions of its health care agenda. Since January, the Administration has solicited feedback on a range of ACA-related regulations and guidance that can be revisited. The RFI is an excellent opportunity for stakeholders to highlight the diversity of perspectives regarding future CMMI initiatives and the continued transition to value-based care.
In a Wall Street Journal op-ed announcing the RFI, Administrator Verma noted the following:
Clinicians, patients, entrepreneurs, state officials and others are busy designing new and better ways to provide health care. There are a lot of great ideas, and we want to hear from people on the front lines. No government agency has all of the answers, especially in an industry as large and multifaceted as health care. 5
CMS is interested in stakeholder input on ideas and concepts to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, increase transparency and competition, and improve measures of quality, cost, and outcomes. CMS also welcomes input regarding its focus in the following eight 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, including Medicaid-focused models;
- mental and behavioral health models; and
- program integrity.
As noted above, comments must be submitted electronically to CMS by November 20, 2017.
Footnotes
[1] Centers
for Medicare & Medicaid Services: Innovation Center New
Direction, CMS.gov,
https://innovation.cms.gov/initiatives/direction (last updated
Sept. 20, 2017).
[2] 82 Fed. Reg. 30010 (June
30, 2017).
[3] 82 Fed. Reg. 10961 (Feb.
17, 2017) (final rule delaying until March 21, 2017, the effective
date of any provisions of the EPM final rule that were to become
effective on February 18, 2017); 82 Fed. Reg. 14464 (Mar. 21, 2017)
(interim final rule delaying the effective date of the provisions
that were to take effect March 21, 2017 until May 20, 2017, and
further delaying applicability date for the EPMs and CR Incentive
Payment Model provisions and effective date for conforming changes
to the CJR Model until October 1, 2017); 82 Fed. Reg. 22895 (May
19, 2017) (final rule setting January 1, 2018 applicability date
and effective date for conforming changes to the CJR Model).
[4] 82 Fed. Reg. 39310 (Aug.
17, 2017). CMS proposed that the CJR Model would continue on a
mandatory basis in approximately half of the selected geographic
areas (34 of the 67 selected geographic areas), with an exception
for low-volume and rural hospitals, and continue on a voluntary
basis in the other areas (33 of the 67 selected geographic areas)
starting on February 1, 2018. CMS proposed to cancel the EPMs
providing for mandatory bundles for heart attack treatment, bypass
surgery, and surgical hip and femur fracture treatment and the CR
Incentive Payment Model before they took effect.
[5] Seema Verma,
Medicare and Medicaid Need Innovation, WALL ST. J. (Sept.
19, 2017, 7:00 PM),
https://www.wsj.com/articles/medicare-and-medicaid-need-innovation-1505862017.
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