The Center for Medicare & Medicaid Innovation (CMMI) is seeking ideas on how to better drive change and reduce regulatory burden. CMMI solicited ideas to shape the agency’s future activities through a September 2017 “request for information” (RFI). The RFI is consistent with the administration’s goal to encourage market-driven innovation and may present a significant opportunity for providers and other organizations to shape future changes to the Medicare and Medicaid programs.
CMMI is accepting ideas and comments from the public through Nov. 20 via an online survey or by email to CMMI_NewDirection@cms.hhs.gov. Listed below are 10 ideas that may be under consideration at CMMI, in areas including:
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Reducing regulatory burden
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Promoting alignment across payors and migration to risk
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Expanding the design of CMMI models
Reducing Regulatory Burden
1. Following recent Congressional deliberations on the effect of the health care fraud and abuse laws on new models of care, stakeholders may advocate that CMMI permit model participants to “self-implement” waivers of applicable fraud and abuse laws. CMMI could move from the use of model-specific waivers that are narrowly crafted by the agency to an approach akin to that used in the Medicare Shared Savings Program (MSSP) under which ACO governing bodies can waive fraud and abuse laws by deciding that an arrangement is “reasonably related” to the program’s purposes.
2. The Administration has also been focused on reducing regulatory burden, and arguments on how to do so are likely to be well received by the agency. For example, commenters may argue that CMMI’s model application process and materials should be simplified to reduce regulatory burden. In that vein, CMMI could articulate consistent requirements applicable to the models being tested, rather than creating “one-off” approaches for each unique model. Application and participation burden could be reduced through the use of uniform processes, expectations, principles and rules that span different models (i.e., population-health, episodes of care, chronic conditions, care transitions) being tested.
3. It is likely that stakeholders will focus on the interplay between the implementation of the Quality Payment Program (QPP) and CMMI. We anticipate comments advocating for the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to be given robust resources and authority to test physician-driven Alternative Payment Models (APMs). For example, stakeholders may advocate for a shorter timeframe than the proposed 18-month PTAC review cycle and ask the agency to implement a “fast-track” process and empower the PTAC to test proposals.
Promoting Alignment Across Payors and Migration to Risk
4. The agency may be asked to build on some aspects of the QPP to encourage models and approaches that build on existing structures, align Medicare and Medicaid, and incent timely migration to financial risk. Potential strategies include permitting already existing networks (i.e., CINs, IPAs, etc.) to participate without having to create new entities, adjusting minimum savings rate requirements to encourage participation and increase early-term payouts, and permitting organizations that commit to migrate from pure fee-for-service to risk over a defined time period (e.g., five years) to qualify as Advanced APMs (and therefore make the entity eligible for Medicare payment bonuses).
5. Further, commenters could urge CMMI to define creative “financial risk” standards for Advanced APMs in ways that couple the requirements of the QPP with pragmatic perspectives of what constitutes “financial risk.” One possible approach would be to permit documented investments in value-based infrastructure (e.g., electronic health records, population health technology, data interfaces, care coordination systems and others) to be considered in APM risk calculations.
6. The agency may receive queries to consider CMMI-private partnerships to make reinsurance more affordable, and to stimulate other means to migrate from fee-for-service to risk. In that vein, CMMI could help manage the predictability of innovative models, and by doing so, limit potential operational costs and increase involvement.
Expanding the Design of CMMI Models
7. To allow greater participation in its models, CMMI may be asked to raise caps on gainsharing payments under models such as the Bundled Payment for Care Improvement initiative to permit greater rewards to providers whose care delivery practices drive improvement and change.
8. Building on stakeholder comments in regard to the QPP, the agency may be urged to adjust approaches to the measurement and use of quality in CMMI models. For example, CMMI could replace scaling of financial rewards that require significant improvements in quality with models that focus on preserving minimum levels of quality or provide rewards for more modest improvements from current performance.
9. Given ongoing concern about how “cost” is measured by CMS and other payors, commenters may urge CMMI to refocus “cost of care” measures to consider broader cost categories. For example, many commercial value-based and at-risk models include pharmacy costs in the total cost of care as a means to encourage providers to modify prescribing practices.
10. CMMI is likely to be pressed for models that encourage participation of providers and suppliers across the continuum of care, to include freestanding ambulatory surgery centers, post-acute providers and others. Commenters may argue that the proactive creation of models for such entities would create a more inclusive approach and allow CMMI to gain useful data to assess how collaboration among different provider types can create savings, address quality and drive innovation.
