REGULATORY REVIEW
CMMI: Pursuing Innovation in Medicare and Medicaid A brief history BY ALEX TAIRA
In March 2010, after more than a year of develop- ment, President Obama signed into law the Patient Protection and Affordable
Care Act (PPACA). The 900-page law represented the most significant over- haul of the US health care system since the 1960s, directing billions of dol- lars toward a plethora of new health care programs. Of particular note was Part III, Sec. 3021, which created a new Center for Medicare & Medicaid Innovation (referred to as CMI in the bill, now commonly known as CMMI) within the larger Centers for Medicare & Medicaid Services (CMS). In the ensuing years, CMMI has been the sub- ject of intense scrutiny from the health care community, a battleground for pol- icy innovations related to care delivery and payment reform. With the Trump administration signaling renewed com- mitment to the center, even amidst bud- get uncertainty, it seems worthwhile to review CMMI’s activity, and where it might go in the future. CMMI has not yet engaged with
any grants involving ASCs, though the ASC community has signaled willing- ness in recent years to engage in new, innovative payment models. Bundling payments, particularly for joint replace- ment procedures, is seen as good candi- date for a CMMI-type test model.
Beginnings: A 10-Year Mandate for Innovation The PPACA laid some basic logistical guidelines to get CMMI off the ground and running. The expressed purpose of CMMI was to “test innovative payment and service delivery models to reduce program expenditures . . . while pre- serving or enhancing the quality of care furnished.” Though the mandate was intentionally broad—the Secretary of Health and Human Services (HHS) was
CMMI has been the subject of intense scrutiny from the health care community, a battleground for policy innovations related to care delivery and payment reform.”
— Alex Taira, ASCA
meant to have great discretionary power to select payment and care models to test—the law did delineate 18 model examples as guidance. These ranged from general (promote care coordi- nation between providers and suppli- ers) to more specific (varying payment methodologies for advanced diagnos- tic imaging services). The center would begin carrying out duties no later than January 1, 2011, and was funded by $10 billion federal appropriation intended to renew every decade. Importantly, this meant that test models selected would have no budget neutrality requirement, although expansion of a model past the test phase would require the CMS actu- ary to show no increase in net spending. CMS Administrator Don
Ber-
wick had appointed Richard Gilfillan, MD, acting director of CMMI, and by March 2012 the new sub-agency had almost 200 staff members. The rapid staffing matched early programmatic implementation; the first year saw 12 initiatives launched, some of which, including the Bundled Payment for Care Improvement (BPCI) and Com- prehensive Primary Care (CPC) Initia- tive, are still ongoing today.
Transitions: Expansion from Voluntary to Mandatory Models In June 2013, CMS Chief Medical Officer Patrick Conway succeeded Gilfillan as director of CMMI, a post
20 ASC FOCUS SEPTEMBER 2018 |
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he would serve until the end of the Obama administration in 2017. CMMI would get swept into more change in June 2015 with the pass- ing of the Medicare Access and CHIP Reauthorization Act (MACRA). The legislation, meant to reform the way in which physicians are paid under Medi- care, provided incentives for physi- cians to join alternative payment mod- els (APMs), of which CMMI had been the primary ground for testing and development. At that time, CMMI was running roughly 60 APM models in a number of different categories. Meanwhile, early test models were
beginning to show promising returns, most notably the Pioneer Account- able Care Organization (ACO) Model, which was the first to meet the PPACA expansion criteria (no net spending and no reduction in quality or access of care). In January 2015, Department of Health and Human Services (HHS) Secretary Sylvia Burwell set new goals for CMMI: 30 percent of Medicare payments delivered through APMs by the end of 2016 and 50 percent by 2018. Though seen as ambitious, Con- way announced that the 2016 goal had been met almost a year ahead of sched- ule in March 2016. This coincided with the rollout of CMMI’s first mandatory model, the Comprehensive Care for Joint Replacement (CJR) model, which made roughly 800 hospitals responsible for patient recovery until 90 days post- discharge for hip and knee replacement “episodes of care.” Although viewed apprehensively, most industry stake- holders viewed CJR as an indicator of mandatory models to come.
By December 2016, in its final
report to Congress under the Obama administration, CMMI reported that 18 million individuals had been impacted by, received care, or would
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