Value Based Payment

Sept. 3-6: Deadline Coming for Latest CMMI Model, With More Options Ahead

August 31, 2018 9:45 am

The CMS executive in charge of creating and tweaking Medicare payment models shrugged off the possibility that many ACOs could leave the program after proposed changes.


Aug. 30—Even as physicians ponder joining a new Medicare Advantage (MA) payment model before next week’s deadline, they should expect more options in the coming months, according to the leader responsible for generating such arrangements.

Physicians are facing a Sept. 6 deadline to apply for inclusion in the MA Qualifying Payment Arrangement Incentive (MAQI) demonstration, which aims to test an exemption for Merit Based Incentive Payment System (MIPS)-eligible clinicians from quality reporting and pay cuts if they are in a qualifying MA payment arrangements.

MAQI is just the latest demonstration model from the powerful Center for Medicare & Medicaid Innovation (CMMI), which operates under the Centers for Medicare & Medicaid Services (CMS). The Affordable Care Act (ACA) gave CMMI a permanent $10 billion annual budget to test new models and the authority to implement them across Medicare, if it chose.

The recently appointed director of CMMI, Adam Boehler, said this week that providers should expect a slew of new payment models over the coming months.

“It takes a little while to build your pipeline, but over the next several months, you’ll see us get in a rhythm of announcements of new models and things we want to do,” Boehler said at press briefing.

Specific areas where the healthcare industry should expect new payment models include social determinants of health, home health, and drugs.

Physician Focus

Boehler plans to attend next week’s meeting of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was created to forward model ideas to the secretary of the U.S. Department of Health and Human Services (HHS). Alex Azar, HHS secretary, appeared to some to reject in a June letter all 10 payment models that PTAC had recommended.

This week, Boehler said the PTAC models, which he called “very realistic and viable solutions,” have not been dropped.

“We are very closely looking at a number of things that they recommended in the original 10” proposals, Boehler said about PTAC. “You will see models that are based on those.”

One reason such models are important is that they would increase physicians’ advanced alternative payment model (APM) options. Physicians who qualify under Medicare’s APM track garner 5 percent annual bonuses of their total Part B payments instead of facing extensive quality reporting requirements and potential payment cuts under the alternative Medicare pay system—MIPS.

“We obviously want to get more APMs out there,” Boehler said.

But physician advocates have increasingly raised doubts about the intent of CMMI to offer more physician-focused APMs because so few models have emerged and few physicians have joined APMs. And nearly two of the five years that APM bonuses are available have passed.

“I won’t pretend that there wasn’t kind of a hiccup when there wasn’t anybody at CMMI leading it, but I will say we have gotten things very much back on track,” Boehler said.

Boehler said “a lot more” physicians will participate in value-based payment models, like accountable care organizations (ACOs), if CMMI can design them “in a way that works for them.”

“For CMMI, we don’t have to reinvent the world on everything,” Boehler said. “Our job is to look at best practices and mimic whatever makes a lot of sense.”

Hospital Concerns

Some hospital advocates have raised concerns that a proposed overhaul of the Medicare Shared Savings Program (MSSP) ACOs will unfairly favor physician-led versions. In addition, ACO changes would require all of them to take on downside risk within two years, instead for the current six-year timeframe.

Boehler underscored the need for ACOs to have “accountability.”

“If everything is upside and an option in value, then you don’t really invest,” Boehler said.

Some have raised concerns about the consequences of requiring all ACOs to move to downside financial risk. Asked about such a move by 2019, more than 70 percent of ACOs responding to a May 2018 poll said they would leave the program, according to the survey by the National Association of ACOs (NAACOS). Estimates by CMS also expected 109 ACOs to leave the program if its proposed changes go into effect.

 “That could be OK,” Boehler said about potential departures. “Our job isn’t to have a lot of ACOs. Our job is to improve performance—to drive costs [down] and improve quality. And so there are some people that should be in an ACO and some that shouldn’t.”

However, CMMI needs to make the program simpler and more transparent, Boehler said.

In response to growing indications that the shift to value-based payment has been slower than expected, Boehler was optimistic.

“Look at the results of the Next Gen ACO versus the original [MSSP] ACOs; that’s accountability,” Boehler said.

A CMS contractor recently issued a report that the 18 Next Generation ACOs cut Medicare spending in their first year—2016—by 1.7 percent, or about $100 million.

“You will see a fairly significant change in that area,” Boehler said. But that will “not necessarily” include more mandatory payment models—at least where large amounts of risk are concerned.

“There are certain areas where you say ‘We can’t be bold and make changes unless we consider this [mandatory] avenue because you’re going to get major selection bias—only the good people will go in,” Boehler said.

Tuesday, Sept. 4

Webinar by CMS titled “The Section M: Skin Conditions.” Learn more.

Public hearing by the Food and Drug Administration titled ““Facilitating Competition and Innovation in the Biological Products Marketplace.” Learn more.

B. Riley’s Healthcare Investor Conference. Learn more.

Hospice provider preview reports available for CMS’s November 2018 Hospice Compare refresh. Learn more.

Wednesday, Sept. 5

Webinar providing an overview of CMS’s Integrated Care for Kids (InCK) Model. Register.

Webinar by the Agency for Healthcare Research and Quality (AHRQ) titled “Healthcare Cost and Utilization Project (HCUP) Database Overview.” Learn more.

Meeting of the Association for Accessible Medicines titled “GRx+Biosims.” Learn more.

Webconference by the Advisory Board titled “Create Care Standards Your Frontline Nurses Will Embrace.” Learn more.

Oral arguments in the Texas lawsuit that contends the Affordable Care Act is unconstitutional.

Webinar by America’s Health Insurance Plans (AHIP) titled “Member Experience: Using AI to Bring Real Value.” Learn more.

Webinar by The National Human Trafficking Training and Technical Assistance Center titled “Human Trafficking and Individuals with Disabilities.” Learn more.

Thursday, Sept. 6

Meeting of the Physician-Focused Payment Model Technical Advisory Committee (through Sept. 7). Learn more.

Deadline for physician applications to the Medicare Advantage Qualifying Incentive Arrangement (MAQI) demonstration. Learn more.

Webinar by CMS titled “Person-Centered Approaches to Support People Dually Eligible for Medicare and Medicaid.” Learn more.

Webinar by AHIP titled “Winning Value-Based Strategies for Budgeted Health Care.” Learn more.

Registration deadline for an AHRQ workshop titled “An In-Depth Exploration of HCUP Resources to Study Hospital Utilization for Opioid, Alcohol, and Other Substances.” Learn more.

Webconference by the Advisory Board titled “The Decision Machine: Analytics and the Rise of AI.” Learn more.

Public meeting of the Medicare Payment Advisory Commission. Learn more.

Friday, Sept. 7

Public meeting of the Medicare Payment Advisory Commission. Learn more.


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