With the Future of CMMI in Dynamic Flux, One Federal Advocacy Leader Shares His Perspectives

March 14, 2018
Like leaders of other healthcare professional associations, Blair Childs of Premier Inc. has been carefully watching what’s been happening with the Center for Medicare and Medicaid Innovation (CMMI), as CMMI’s payment innovation work remains an industry focus

With so much in a state of flux in Washington, D.C. these days when it comes to federal healthcare policy, policy and advocacy leaders across U.S. healthcare have been particularly anxious to get a sense of where the Center for Medicare and Medicaid Innovation (CMMI), also referred to as the CMS Innovation Center, might be headed. CMMI is a center for payment innovation within the federal Centers for Medicare and Medicaid Services (CMS). As described on its website, “The Innovation Center allows the Medicare and Medicaid programs to test models that improve care, lower costs, and better align payment systems to support patient-centered practices. The Innovation Center carefully evaluates innovative reform efforts widely used in the private sector, and is unique in its ability to develop provider-proposed approaches and quickly adjust models in response to feedback from clinicians and patients.”

Further, as the website description for CMMI notes, “The Innovation Center was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). 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. Congress provided the Secretary of Health and Human Services (HHS) with the authority to expand the scope and duration of a model being tested through rulemaking, including the option of testing on a nationwide basis.”

At the dawn of the Trump administration, there was considerable concern that CMMI might be shut down entirely; that concern was partly based on statements that Tom Price, M.D. had made when he was a Republican congressman, prior to his appointment as Secretary of Health and Human Services. With the failure of attempts to repeal and replace the ACA this year, and then with Price’s resignation as HHS Secretary, the landscape appears to have changed somewhat.

And while some in the healthcare industry might think that some of the developments around the ongoing dynamics around the CMMI might be perceived as “inside baseball,” some mainstream media are picking up on the significance of the “CMMI question.” For example, in a September 21 report in POLITICO’s “Morning eHealth” section online, Darius Tahir wrote, under the headline, “CMMI DRAMA HITS OPERATIC LEVEL,” “As we teased in Wednesday’s Morning eHealth, CMS’s request for information on CMMI has landed. That’s the controversial office chartered by the Affordable Care Act with sweeping powers to reshape Medicare. The broad brushes are vague, but intriguing, and have piqued the interest of all the players in this drama. Let’s start by reviewing the RFI,” he wrote, linking to the RFI document. “Outlined in broad strokes is the new direction CMS intends to set for the Innovation Center, but the document also emphasizes that CMS wants to hear from you. Of particular interest to eHealth: the center wants to facilitate more advanced payment models; to empower consumer choice (potentially by “facilitat[ing] and encourag[ing] price and quality transparency”); to explore value-based pay models for drugs; to pay for behavioral health in novel ways (potentially by focusing on integrating care); and program integrity (i.e. fighting fraud). The office specifically asks for technologists’ input in the area of consumer choice.”

In fact, Tahir wrote on Sep. 21, “The mere announcement touched off controversy,” noting the fact that
“Former CMS staffer Aisling McDonough argued on Twitter that CMS’s method of soliciting comments was a blow against government transparency. The agency directed readers to submit their thoughts via an informal survey (here), and advised respondents that the agency may or may not publicly post the comments. The information gleaned through this process may be used by the government, the text of the survey further advises. Typically,” Tahir explained, “when the government engages in these sorts of administrative processes, they post the comments online — which is a good way to track what different organizations publicly think about policy. Depending on CMS’s approach to the information it gathers, outside observers will lose a tool to track the government’s policy process.”

Meanwhile, just two days earlier, on Sep. 19, CMS Administrator Seema Verma had published an op-ed in the Wall Street Journal, in which she stated that CMMI is interested in testing models in eight focus areas including increased participation in advanced alternative payment models, consumer-directed care and market-based innovation, 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. “Providers need the freedom to design and offer new approaches to delivering care,” Verma wrote. “Our goal is to increase flexibility by providing more waivers from current requirements.” Further, she said, CMS wants to see more competition between providers to compete for patients in a free market system. Transparency is needed for consumers to be more cost-conscious, she emphasized. “We will move away from the assumption that Washington can engineer a more efficient healthcare system from afar -- that we should specify the processes healthcare providers are required to follow,” Verma added.

Premier weighs in

The Charlotte-based Premier Inc., a nationwide collaborative of hospitals and other provider organizations, is one of the national healthcare professional associations that has been watching developments very closely. As Premier noted in a bulletin to its member organizations late last month, “CMS has solicited input on ‘new direction’ for the Center for Medicaid and Medicare Innovation Center. Reading the tea leaves, CMS Administrator Seema Verma has laid out some thoughts on where the organization may be heading, including the need to focus on creating new payment models that move from fee-for-service to paying for value, holding providers accountable for outcomes; as well as empowering patients with information to seek value and quality as they shop for services.” That “What We’re Watching” bulletin went on to say, “What we’re saying: We are strongly encouraged that there is still a strong commitment to moving toward value-based, alternative payment models that promote high-value care, but we’d like to see increased incentives for providers moving in this direction. We highlight additional strategies CMS should consider in the efforts to improve the value-based care movement and would love to speak with you about what we’re seeking here.”

Blair Childs

In that context, Healthcare Informatics Editor-in-Chief Mark Hagland recently interviewed Blair Childs, Premier’s senior vice president of public affairs, about the current moment. Below are excerpts from that interview.

Where does Premier stand with regard to the role that CMMI can or might play going forward, and what do you think will happen with CMMI in the near future?

It’s definitely surviving; the fact that they put out the RFI [request for input], gives the clear sense that they remain committed to CMMI, and realize it’s an important tool in their toolbox. There’s an enormous flexibility they’ve got, with CMMI. Second, everything is really bogged down, though. You don’t have a lot of key spots. And Patrick Conway has left [Patrick Conway, M.D., who had been director of CMMI, announced in August that he was leaving that position to become president and CEO of Blue Cross and Blue Shield of North Carolina, effective Oct. 1], and he’s an incredibly valuable person to have lost. He left on September 18. So he’s gone. But they’re supposed to announce somebody new to that position any day. But [President Donald] Trump made a comment today that he doesn’t want to appoint a lot of people. But I still think that they will, and apparently, have a final candidate, and my understanding is that that person will be a solid person.

What do you think will happen over the short and medium term, at CMMI?

It depends on the leadership. They just did the RFI. If Tom Price were still there, there are things he would be trying to do; but obviously, it could be different, now that he’s gone. So I think right now that it’s a very confused situation. And it’s hard to be predictive until we get a new person in there, and they get the RFI done, and they sift through that. I know everybody’s going to be providing ideas.

What would you like them to do?

We have a whole bunch of recommendations. We’ve been saying for some time that this is a time to have a new level of leadership in HC, and these are all bipartisan ideas—MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] and so forth. We’d like to see more of a use of waivers, to give more flexibility to providers. We have a number of payment model ideas; one is a layered payment model, in which you’d have a more comprehensive way to help providers to manage their costs—primary care, patient-centered medical home, with a capitated model and bundles, inside an ACO [accountable care organization]. We also have an idea for critical access hospitals. We’ve developed a whole health policy roadmap, in fact.

Do you see CMMI as moving forward in a robust way, and really becoming capable of helping to lead transformation in the healthcare system?

The article that Seema Verma put in the Wall Street Journal was pretty good. It talked about the need to pay for value, and so there’s definitely a commitment to that. I don’t think, though, that there is as much of a commitment to the public payer side. There’s much more of a focus on getting private payers to make change. There’s just a lot more focus on, let private payers act, don’t have the government lead. If Hillary Clinton had been elected, you would have seen mandatory bundles executed for a lot of procedure areas. you won’t see that now. But you won’t see a retreat. I just don’t anticipate seeing a lot of new energy.

Is there anything you’d like to add?

We’re in a little bit of a holding pattern right now, until we get clearer direction, from the RFI, and also, supposedly, Seema Verma is going to become more visible and out talking more. When we get a new secretary, that will help, and when we get a new head of CMMI. And Seema Verma is not visible right now in Washington, so there are a lot of openings. I’d like to have some greater clarity.

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