On the CMS.gov website, the Center for Medicare and Medicaid Innovation is deemed the innovation engine for the federal government supporting “the development and testing of innovative health care payment and service delivery models.” On its website, www.innovation.cms.gov, it reports a wide range of 60 active initiatives funded by its $1.3 billion annual budget including the Comprehensive Primary Care Plus, Medicare Diabetes Prevention Program, the Vermont All-Payer ACO Model, the Medicare Advantage Value-Based Insurance Design Model and many more.
As speculation swirls around the next HHS Secretary nominee, with the names Price, Jindal, Gingrich and others mentioned, the future for CMMI is being debated. Critics say it’s purpose though laudatory has been compromised and funds wasted. They argue its investments have shown marginal return and its impact undermined by the chaos it has created across the system. Supporters counter that the sausage-making necessary to transform the U.S. health system is to be expected: changing course is never easy, especially in healthcare where partisanship runs strong, public opinion is divided, stakeholders are strong in defending their turf and runaway costs threaten the federal government’s credit-worthiness.
No doubt, the prospect for Medicare to transition to a premium support program via Rep. Ryan’s Better Way plan, block grants to states as they assume primary responsibility for Medicaid and relaxing of constraints on private insurers will dominate the politics of health policy in coming weeks. But the role and scope of CMMI deserves attention: it seems to me it has significant potential to markedly improve the performance of the system if it focuses on six major changes:
1-Simplifying and Standardizing Measures of Performance: There are no standard of definitions of and reliable measures for quality, safety, costs and patient experiences across the many sectors in U.S. healthcare. Each defines its own and discounts those of others. The result is confusion, inefficiency and protection of the status quo. Quality is a case in point: the nation’s 4900 hospitals must report to CMS at least 90 measures tying up money and staff, and those don’t include proprietary quality reporting by groups like Leapfrog, HealthGrades and many others that request data. And the mother of them all is value: deducing how it is calculated requires a consistent and complete view of total costs of care that’s inclusive and an economic construct that associates costs and results holistically. Might CMMI be the convener that eliminates confusion and reduces waste by taking the lead in defining important concepts and key metrics?
2-Transparency that’s Accessible and Useful: Accompanying definitions and measures standardization, CMMI could be the one stop shop for report cards on the performance of physicians, counselors, drugs, devices, hospitals, post-acute providers, over-the-counter therapies, alternative providers, pharmacists and private insurers. Consumers are overwhelmed by the avalanche of report cards, star ratings and results reporting. There are more than 800 hospitals that lay claim to being Top 100. Plans can get 5 star ratings in one line of business and 1 in others, reporting requirements vary by state. The efficacy and effectiveness of drugs is largely inaccessible to prescribers and users. Alternative health is a vast wasteland for scientific evidence undermining consistent integration of therapies shown to work. And state-led efforts have heightened inconsistency of reporting requirements and costs-of-reporting for stakeholders. Thus, state officials, who will bear the brunt of system transformation in coming years have marginal access to data useful in knowing what works, what doesn’t and how to respond.
3-Increasing Incentives in Alternative Payment Programs: After three years, one in four participants in the Medicare Shared Savings programs has saved money for Medicare: the rest have spent more with consultants and technologies than they’ll likely ever recover. Bundled payments for joint replacements showed promise, but for 47 other episodes of care arguably more complicated than a knee or hip, the jury’s out. Penalties associated with value-based purchasing for hospitals, avoidable complications and readmissions, poor safety and the litany of punitive programs marginalize system improvements and innovation efforts. Dollars that could be invested in systemic improvements and innovation are instead spent on compliance and penalty avoidance. Identifying those programs that show definitive return on investment, enhancing incentives in these, relaxing compliance rules and promoting these across the entire system makes sense for CMMI.
4-Innovating in Primary Care: Primary care is ground zero for reducing demand and unnecessary utilization of the health system. CMMI’s efforts in its 10 current primary care transformation projects are helpful, but the reality is this: in rural areas, access to primary care providers is spotty at best. In urban areas, it’s highly variable. Consumers willingly accept that advanced practice nurses, retail clinics, and telemedicine are viable options, and health services research shows that social determinants, access to mental health and dental care are central to primary care. To reduce demand and unnecessary costs, CMMI can be the engine for expanded models of primary care that leverage technology and the skillfulness of a wider range of professionals in addition to physicians and nurses.
5-Improving Individual Accountability: The U.S. health system’s fatal flaw is its abject rejection of the notion that individuals can navigate the health system given the right tools. No one chooses to be ignorant. In healthcare, lack of understanding about how our health system works is the unintended result of how we operate. We obfuscate scientific evidence, ignore behavioral economics in engineering our programs and defer to clinical experts because it’s easier. There are simple places to start, like increasing medication adherence which falls short for two in three prescription users, or keeping scheduled appointments. The surging success of self-administered diagnostic testing technologies confirms consumers have an appetite to know about their health and what it costs. And unhealthy lifestyle choices are the leading driver of health costs. So, for CMMI, tapping into a construct that transitions the health system from its latent acceptance that patients are dependents to persons who are activists seems an important CMMI focus.
6-Streamlining the CMMI Portfolio: Per section 3021 of the Affordable Care Act, the tri-focus of its programs are 1-Testing new payment and service delivery models, 2-Evaluating results and advancing best practices and 3-Engaging a broad range of stakeholders to develop additional models for testing. Its funding was authorized in the ACA: $10 billion for 2010-2019. Since 2010, its 30 operating divisions have launched 70 initiatives including 10 “no longer active” and 13 “announced”: accountable care (12 models/programs), episode-based payments (12 programs), primary care transformation (10 programs), Medicaid & CHIP (8 programs), dual eligibles (3 programs), new payment/service delivery models (22), and adoption of best practices (11 programs). Understandably, the sheer volume of programs and requisite mechanics for applying, complying and potentially benefiting from participation have sparked industry frustration. The Medical Group Management Association, American Hospital Association, Pharmaceutical Research and Manufacturers Association along with 170 members of Congress have asked CMMI to slow its pace and engage industry leaders more effectively in the design of its programs. Their concerns are justified: it’s hard to maintain day to day operations in an environment that’s dicey already. Adding programs that can be suspended at will or deemed mandatory by caveat puts added unnecessary pressure on the system.
As the new administration steps in and repeal of the Affordable Care Act takes center stage, it’s possible a new focus for CMMI can be part of its replacement. It can play a critical role in achieving the system’s triple aim if focused and effective. Perhaps it’s time for fresh thinking about CMMI.
The Center for Medicare and Medicaid Innovation inACA Section 3021, General Description: “There is created within the Centers for Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the ‘CMI’) to carry out the duties described in this section. The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph 4A”