CMMI’s Fowler: More Mandatory Payment Models Likely
- The CMS agency which is testing ways to inject more value into federal health programs is likely to start testing more mandatory payment models, its director hinted Thursday.
- Elizabeth Fowler, director of the Center for Medicare and Medicaid Innovation, said the review of CMMI’s ongoing strategy has resulted in more conscious choices in where it should invest, which includes moving away from voluntary models.
- “Voluntary models are subject to a selection of risks, which has a negative impact on the ability to generate savings at the system level. Suppliers who don’t generate additional income tend to leave the program, and those who tend to stay, ”Fowler, now in his third month on the job, said at a health affairs briefing. “So we are exploring more mandatory models.”
CMMI began reviewing more mandatory models under the Trump administration, and the agency chief under President Joe Biden signaled on Thursday that this direction is likely to continue. The problem with relying too much on voluntary models, Fowler said, is that federal law determining whether CMMI models succeed rests on whether the model has reduced costs throughout the system.
Determining this is difficult when providers, reluctant to take on the financial risk, leave the model and only those who perform well remain. As a result, it is likely CMMI will rely more on mandatory models in the future, the director said.
“I recognize that these come with their own set of drawbacks… But I support that direction,” Fowler said.
CMMI is currently in the midst of a strategic review and has suspended a number of models during the evaluation, including the geographic direct contract model and the severe primary care first population model. CMMI has also delayed the start dates for the Kidney Care Choices model, among others.
The agency was founded ten years ago with the passage of the Affordable Care Act, with the aim of advancing the needle towards paying for quality health care rather than quantity. However, few models of CMMI resulted in cost savings or better quality of care, which prompted a bipartisan group of lawmakers to advocate for increased oversight of the agency more than a year ago.
CMMI has tested 54 models in its ten years of existence, but only four of them have definitively become Medicare members.
“We have to move away from this spaghetti-against-the-wall approach, see-what-flowers-bloom and double what we see is working,” Fowler said. “As a general principle, I think we want to focus on our strategies aligned with the overall goal of health system transformation. “
It means clearing the way for organizations heavily involved in value-based care, pushing back the laggards, and reaching out to those who haven’t been involved historically. It’s also linked to the administration’s focus on health equity, which Biden’s senior health policy makers have stressed will remain the top priority when developing new models and regulations.
In the past, CMMI focused on the certification of models and their implementation in Medicare, as it has greater statutory authority within that plan. But this concentration can be limiting. Fowler said Thursday she was ordered by newly confirmed CMS chief Chiquita Brooks-LaSure to further examine the test patterns in the Medicaid safety net program.
“We will be looking at more Medicaid models,” Fowler said. “We would like to spend more time working with states.”
And encouraged by HHS Secretary Xavier Becerra, CMMI is also exploring how it could help increase access to cost-effective behavioral health care, as mental health issues like anxiety and depression have been severely exacerbated over the course of of the pandemic.
But despite CMMI’s goal of injecting more value into U.S. healthcare, it’s unlikely Fee-for-service payments will be phased out, Fowler told Health Affairs editor Alan Weil.
“I don’t see everyone moving into managed care,” Fowler said. “But I hope there is an alignment where someone is caring for you in a meaningful way.”