- The CMS agency that tests ways to inject more value in federal healthcare programs is likely to start trialing more mandatory payment models, its director hinted on Thursday.
- Elizabeth Fowler, head of the Center for Medicare and Medicaid Innovation, said that CMMI's ongoing strategy review has resulted in more conscious choices in where it should invest, which includes pivoting away from voluntary models.
- "Voluntary models are subject to risk selection, which has a negative impact on the ability to generate system-level savings. Providers that aren't generating the extra revenue tend to exit the program, and those that are tend to stay," Fowler, now on her third month at the job, said at a Health Affairs briefing. "So we are exploring more mandatory models."
CMMI began looking into trialing more mandatory models during the Trump administration, and the agency's head under President Joe Biden signaled Thursday that direction is likely to continue. The issue with relying too heavily on voluntary models, Fowler said, is that the federal statute determining whether CMMI models are successful relies on whether the model reduced cost across the entire system.
Determining that is difficult when providers, leery of assuming financial risk, leave the model, and only those performing well stay. As a result, it's likely CMMI will lean more heavily on mandatory models moving forward, the director said.
"I recognize those come with their own set of disadvantages... But I support this direction," Fowler said.
CMMI is currently in the middle of a strategic review, and has paused a number of models during the evaluation, including the Geographic Direct Contracting Model and the Primary Care First Serious Illness Population Model. CMMI has also delayed the start dates for the Kidney Care Choices model, among others.
The agency was founded 10 years ago with the passage of the Affordable Care Act, with an aim to move the needle toward paying for quality of healthcare instead of quantity. However, few of CMMI's models have resulted in cost savings or better quality of care, causing a bipartisan group of legislators to advocate for more oversight of the agency more than a year ago.
CMMI has tested 54 models over its decade-long tenure, but only four have gone on to permanently become part of Medicare.
"We need to move away from this spaghetti-against-the-wall, see-what-flowers-bloom approach and double down on what we see is working," Fowler said. "Going forward as a general principle I think we want to focus on our strategies aligned with the overall goal of health system transformation."
That involves clearing a path for organizations heavily involved with value-based care, pushing laggards forward and reaching those that historically haven't been involved. It also ties in with the administration's focus on health equity, something Biden's top health policy appointees have stressed will remain top of mind when shaping new models and regulations.
In the past, CMMI has focused on certifying models and enacting them in Medicare, because it has more statutory authority within that scheme. But that focus can be limiting. Fowler said Thursday that she's received direction from newly confirmed CMS head Chiquita Brooks-LaSure to look more deeply into testing models in the safety-net Medicaid program as well.
"We'll look at more Medicaid models," Fowler said. "We'd like to spend more time working with states."
And urged by HHS Secretary Xavier Becerra, CMMI is also exploring how it could help increase access to cost-effective behavioral healthcare, as mental health conditions like anxiety and depression have been severely exacerbated over the course of the pandemic.
But despite CMMI's goal to inject more value into U.S. medical care, it's unlikely fee-for-service payments will ever be phased out entirely, Fowler told Health Affairs editor in chief Alan Weil.
"I don't see everyone moving into managed care," Fowler said. "But hopefully there's an alignment where someone's looking out for your care in a meaningful way."