Innovation and Disruption

CMMI chief: Administration’s value push will continue if ACA struck down

July 8, 2019 3:56 pm

The senior government official in charge of creating value-based payment models said the Trump administration’s commitment to such models would continue even if the law authorizing his office is struck down in an ongoing court challenge.

The administration has joined a lawsuit of state attorneys general in challenging the constitutionality of the Affordable Care Act (ACA), which created the Center for Medicare and Medicaid Innovation (CMMI). But Adam Boehler, director of CMMI, recently told provider and health plan executives that the administration would continue its shift to value-based payment in Medicare and Medicaid even if the ACA is struck down.

In December, a federal judge ruled the law unconstitutional, but the ruling was stayed pending an appeal. The administration joined on the side of the states opposing the law

“What I would emphasize is the administration’s commitment to value-based care,” Boehler said in June at the ACO, Bundled Payment and MACRA Summit. “Independent of what happens one way or the other, I think you would see that commitment.”

If a final court ruling eliminated CMMI — and its $10 billion 10-year budget for testing new models — “I’m sure that would be addressed if necessary,” Boehler said.

New models will have a different look and feel

Although Boehler committed to continuing existing models, such as bundled payments and accountable care organizations (ACOs), he also promised changes in coming models.

CMMI’s new goals include “moving the government off of fee for service [FFS], away from FFS risk, and switching to a payment system that pays for outcomes instead of activity,” Boehler said. Previous CMMI models took an FFS core and wrapped value-based payments around it, he said

The primary care models unveiled in the spring, in contrast, “eliminate the FFS core; they’re just outcome-based models,” Boehler said.

Among coming models, some will be mandatory for some providers.

“If it’s not necessary for the model, I’d rather make it voluntary if we can,” Boehler said.

Key elements in coming models are:

  • Simplicity
  • Predictability
  • Transparency of data
  • Participation by multiple payers

Some of the new models will be based on recommendations of the Physician-Focused Payment Model Technical Advisory Committee (P-TAC).

 The next new CMMI models, which Boehler said will be announced “soon,” could focus on kidney care. Those could implement Medicare’s goals to increase the home dialysis rate from 11% to 50% and cut the average wait time for kidney transplants from three years to less than a year.

“You’ll see some real change in incentives for transplant and home [dialysis], broadly,” Boehler said, noting that kidney care consumes one-quarter of Medicare spending.

The order of implementation of models focused on other disease groups will be determined by:

  • Impact on costs
  • Impact on quality
  • Degree of difficulty in execution

“That’s essentially how we prioritize,” said Boehler.

Physician model focus

The Direct Contracting (DC) and Primary Care First (PCF) models introduced in the spring are emblematic of the coming generation of CMMI models, Boehler said.

The DC model is for “more sophisticated players” that can take on the required 50% or more downside risk on total cost of care, Boehler said. The PCF models aim for participation by smaller practices by splitting payments between per-visit and monthly fees, while only 10% is at risk based on a simple metric — risk-adjusted admissions.

In CMMI focus groups, some small-practice representatives said they couldn’t take any downside risk. But Boehler said they could because:

  • Existing revenue cycle realities already place 10% at risk.
  • The model allows for a range of risk from break-even to a 50% upside.
  • The model allows for a focus on patients instead of metrics.
  • The model will reduce administrative burdens.

For those reasons — and citing positive physician feedback — he believes the new primary care models will reach CMMI’s goal of enrolling one-quarter of all primary care physicians.

“As we look at other specialties, you’ll see this kind of approach,” Boehler said.


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