REGULATORY REVIEW


soon receive care from a provider par- ticipating in a CMMI model.


An Uncertain Future Under the New Administration The arrival of the Trump Administra- tion in February 2017 brought signif- icant uncertainty to CMMI and HHS as a whole. Although the health care industry had been generally support- ive of the investing in innovative care and payment delivery models, many were troubled by the trend of manda- tory models, seeing it as on overstep- ping of CMMI’s statutory authority. Incoming HHS Secretary Tom Price had been particularly critical of man- datory pilots during his time in Con- gress, asserting that these models were the government dictating to physicians how to practice. With the new adminis- tration promising rollbacks in Obama- era health reforms and overall spend- ing, the $10 billion per decade CMMI budget seemed like a logical program for the chopping block.


Upon taking office, Price acted


quickly, rolling back impending man- datory orthopedic and cardiac bundled payment programs. In September 2017, new CMS Administrator Seema Verma posted an op-ed in the Wall Street Jour- nal announcing a new direction for CMMI. The administration planned to re-orient CMMI around provider flex- ibility, free market principles and con- sumer choice and solicited stakeholder feedback through a request for infor- mation (RFI). Later that same month, however, Price was forced to resign, replaced by pharmaceutical executive Alex Azar. In his nomination hearings, Azar struck a decidedly different tone in relation to CMMI, asserting that models may have to be mandatory in some instances to garner adequate data. In April 2018, Azar appointed Land- mark Health CEO Adam Boehler as CMMI director. The two officials have signaled that the center will become more active in both soliciting and man- aging test models, prioritizing those that


models have only been in operation for a few years and are meant to take four to seven years before being reviewed for expansion. Most models have shown some degree of cost savings, although few have seen enough savings to offset commensurate management or admin- istrative spending increases. Proponents will say that this is just an indication that models take time to refine as payers and providers realign practice and adminis- tration along value-based lines. From a budgetary standpoint,


the


will have immediate impact on health care consumers. In particular, CMMI will likely have a role in revising rules around Medicare


Accountable Care


Organizations (ACOs) and a new, some- what vague “direct provider contracting” model. This is likely, despite continued discussion around larger administration spending cuts including some $800 mil- lion in CMMI budget cuts for 2018 and 2019 (CMMI will receive a new man- datory appropriation renewal in 2020). As of the writing of this article CMMI has 39 active innovation models and five more under development.


Evidence Despite more than seven years of opera- tion, the evidence from CMMI is mixed at best. Some of this is intentional; many


Track the Latest Regulatory and Legislative News for ASCs


Visit ASCA’s website every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs.


www.ascassociation.org/ GovtAffairsUpdate


Congressional Budget Office (CBO) has consistently projected that CMMI will generate net savings in the long term, most recently projecting $45 billion in savings to offset $12 billion in spending 2017–2026. Many have noted that even without these projections, $1 billion per year for CMMI is a drop in the bucket compared to the roughly $3 trillion spent per year on health care. Some of the spe- cific models have shown financial prom- ise as well, such as the risk-bearing ACO models and the hip/knee replacement outpatient payment bundle. Despite this, just two models—the aforementioned Pioneer ACO Model and the Medicare Diabetes Prevention Program (DPP) Model—have met the PPACA criteria for expansion. As previously mentioned, the next


battleground for CMMI will be regard- ing voluntary versus mandatory imple- mentation of models. A new study from the University of Pennsylvania exam- ined hospitals that participated in the voluntary BPCI model against those par- ticipating in the mandatory Comprehen- sive Joint Replacement (CJR) model. Researchers found that although the two programs engaged different types of hospitals (voluntary hospitals tended to be larger and higher-volume), there was no difference in baseline spending, qual- ity of care or risk assumed. It is likely that hospital and physician groups will push back against any new mandatory programs. Whether Azar or Boehler will reinstate any remains to be seen.


ASC FOCUS SEPTEMBER 2018 |www.ascfocus.org 21


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