For the first time at the HIMSS Conference, the Director of the Center for Medicare and Medicaid Innovation (CMMI) offered a press availability during the conference. On Wednesday morning, Feb. 13, Adam Boehler, who became CMMI Director in April 2018, met with members of the press in the Press Room at the Orange County Convention Center in Orlando, during HIMSS19.
Boehler began his remarks by speaking about his personal background; proceeded to outline and underscore CMMI’s top priorities, and explain how those connect to the top priorities of the Centers for Medicare and Medicaid Services (CMS) and of CMS Administrator Seema Verma, and then took questions from members of the press.
Boehler initiated his remarks by sharing with journalists about his personal-professional background. “Most recently,” he noted, “I was CEO of Landmark Health, which takes full risk for very complex chronic patients. Landmark Health has 1,000 employees and 20 locations, and is largest provider of in-home medical care in the country. I started the company from scratch several years ago, he said, noting that “My grandmother, who lived to nearly 100, was in and out of the hospital regularly towards the end of her life, and always left worse. So at Landmark, we went to health plans, and took full risk on these patients, and did 24/7 medical care. And if incentives were aligned, and if we got a call at 2 AM on a Sunday, we would send a doc out for a home visit. Avoid $50,000 of expense by avoiding a hospital admission, it changes the incentive structure around. I was recruited to CMMI by my predecessor, who called me. Patrick [Conway, M.D.] called me and said, hey, would you consider this?
As his official profile at CMS.gov notes, “Adam Boehler, Senior Advisor to the Secretary [of Health and Human Services], CMS Deputy Administrator and Director of the Innovation Center joined CMS in April, 2018. Adam is widely regarded as an innovative leader in the private sector and has designed and implemented new, patient-focused approaches to healthcare delivery.”
“I have two roles,” Boehler told journalists Wednesday. “One is running CMMI, where I work for Administrator Verma. Our goal there is to take cost out and improve quality for the patient, looking at new models. For the Secretary, I look at quality and cost. It’s not restricted just to models, to Medicare and Medicaid, to CMS as an agency. We’ve been spending a lot of time looking at kidney care,” he noted. “For example, we can look at what HRSA does” around research into policy alternatives around kidney care, referring to the Health Resources & Services Administration. “So that’s a broader view of looking at kidney care—one could look at regulatory and legislative approaches. What I like about the combination of both roles is that we can look at models, but also look at potentially asking Congress to take action, or some other approach.”
Speaking of the kinds of innovation that CMMI, CMS, and HHS can promote, Boehler said, “Thematically, in terms of improving healthcare, one element would be releasing the data; and the other is changing the incentives. I think those two things, when combined, are very significant. That’s why Administrator Verma’s rule release is so important. And from a CMMI perspective, we can take that even further in our models, given that we have voluntary participation.”
Speaking of efforts to advance transformation in the healthcare system, Boehler revealed that “CMMI and CMS are going to introduce an AI challenge, shortly, with XPRIZE, in partnership with the American Academy of Physicians. So you’ll see physician participation,” he said. The key, he added, is “to try to be on the edge of redefining quality. One of the things the administration has done a good thing on,” he continued, “is, let’s focus on things that really matter.”
In terms of overall goals within HHS, Boehler said, “There are four keys for the Secretary [Alex Azar, Secretary of Health and Human Services] going forward: focusing on the patient as consumer; on providers as accountable entities; on establishing payment for outcomes; and prevention.”
With regard to holding providers accountable, Boehler said, “We’re big believers in empowering providers. I think it’s very difficult as the federal government to centrally manage healthcare, when every different state is different and every local place is different. So I believe a lot of this involves the agency in empowering providers,” and within that, he said, helping physicians to take on greater amounts of financial risk in their contracting, will be important.
Meanwhile, when it comes to payment for outcomes, Boehler said, “We’re looking to incent keeping people healthy at home.” And when it comes to tipping providers into risk, he said, “We’re hoping doctors will be incented to keep people healthier. I mentioned the kidney industry earlier. We do not think the state of kidney care is acceptable, nor is the level of transparency in that area acceptable,” as an example of one area in which the federal healthcare agencies will work to reengineer payment incentives to incentivize the best behavior on the part of providers.
Indeed, that leads to the issue of payment for incentives, Boehler said. “Payment systems remain mal-aligned” in a number of areas, he insisted. “When you call 911 and the ambulance comes, it’s only paid if you go to the hospital. Now, I don’t want people not to get to the hospital when needed; but if you wanted to treat them at home under physician supervision, you could. We’re looking at this.” Importantly, he noted, 40 percent of Medicare hospital admissions come through 911. “It’s a huge issue,” he said, and “a very simple change [in payment incentives] could make a difference.”
Finally, the fourth key policy area of importance to federal healthcare policy officials, Boehler said, is prevention. “We’ve had a lot of focus on taking cost out” of the U.S. healthcare system. And there’s not enough fat to cut out unless we can prevent disease. Speaking of the need to collect and use social determinants of health data, he asked, “how do we integrate that in the right way? How do we not silo?” Artificial intelligence will be one important tool in moving forward in that area, he noted. Indeed, he said, business intelligence of all kinds will be needed to help the leaders of patient care organizations better predict where intervention will be needed, in order to improve patient outcomes. “Rank-ordering patients on prior expense is a really poor predictor,” he noted. But “rank-ordering them based on risk factors is better.” And AI can be used effectively to support such activities, as well as to help clinicians analyze such elements as the likelihood of inpatient admission in the next 30 days, and the development of septic shock.
After laying out his vision for CMMI, Boehler responded to questions from the journalists gathered at the briefing. In response to a question from Healthcare Innovation related to the question of whether recent comments by CMS Administrator Seema Verma, and rules changes requiring the parameters around participation in the Medicare Shared Savings Program might cause some organizations to leave the MSSP, Boehler said, “What Administrator Verma is doing, which I’m 100 percent in support of, is trying to eliminate a [kind of payment] purgatory. It’s very difficult to have a foot in fee-for-service and a foot in risk. And it’s OK if some people decide it’s not right for them,” he said, referring to the possibility that recent moves intended to accelerate progress by pushing accountable care organizations faster into downside risk in the Medicare Sharing Savings Program. “What you want is the right folks, not everybody. And it’s been seven years” since the MSSP was first created, he pointed out; “there’s never going to be a good time. And it’s time to make a decision, you know? It’s time to commit. And it’s incumbent on us to give predictability of model, and to simplify as much as possible; we’ve heard that from the participants quite a bit. I understand that need, and we’re working on that need.”