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November 30, 2017

Provider groups share their vision for the future of CMMI

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    Provider groups in response to a request for comment called on CMS to use the Center for Medicare and Medicaid Innovation (CMMI) to implement better alternative payment models (APMs) that are transparent and adequately pay providers.

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    Background: CMS asks for input on how to use CMMI

    CMS in September released an informal proposal outlining potential new payment models along with a broader request for health care providers and other stakeholders to submit comments on how the administration could use CMMI to make it easier for the health care industry to work with Medicare. Stakeholders had until Nov. 20 to submit comments in response to the request.

    Stakeholders weigh in

    Several stakeholders indicated their support for the proposal CMS outlined, but expressed concerns and shared recommendations as well.

    James Madara, president of the American Medical Association (AMA), in a comment letter wrote that the association "welcomes [a] new direction for CMMI because we are convinced that it can implement more and better APMs more quickly and effectively than it has to date."

    Madara wrote, "Physicians are willing to participate in APMs that hold them accountable for decisions on the appropriateness of tests they order, procedures they perform, medications they administer, and whether patients are discharged to their homes or to expensive facilities, but they are not willing nor should CMMI expect them to take risk for things they cannot control, such as the prices of drugs and biologics or the severity mix of their patient population." Madara said CMMI in the past implemented payment models that failed to adequately pay for providers for services and "inappropriately transfer(ed) insurance risk to physicians."

    Madara in the letter also asked CMMI to establish "reasonable deadlines" for applicants and to conduct limited-scale testing of APMs within six months after the center receives a detailed APM proposal.

    Jacqueline Fincher, who chairs the Medical Practice and Quality Committee for the American College of Physicians (ACP), in a comment letter wrote that CMMI should not "mov[e] too quickly" and instead should take time to further develop performance measures and systems. Fincher wrote, "Until quality measures are developed that appropriately assess high priority areas and improved patient outcomes, patients will not have valid and reliable data available with which to properly assess quality."

    Madara and Fincher in the letters separately said new payment models should be implemented on a voluntary basis. Fincher said CMMI should "minimize" the number of APM applicants in "defined control groups," noting that such applicants might not be able to benefit from bonuses other providers outside of the control group receive. 

    AMGA, previously known as the American Medical Group Association, in a comment letter recommended CMS use CMMI to test patient reported outcome measures (PROMs) and incentives designed to boost health IT interoperability and to foster competition among Medicare fee-for-service, accountable care organizations (ACOs), and Medicare Advantage programs. AMGA recommended CMMI create a "glide path" for ACOs to "incrementally move into risk arrangements" and that the center make ACO performance data "fully transparent."

    The American Hospital Association (AHA) in a comment letter wrote that CMMI in the future should design payment models rooted in transparency to allow participants to make informed decisions. AHA said future payment models should strike a balance between risks and rewards in such a way that providers are encouraged to take risks, but those that are unable to do so are not penalized. AHA said payment models should minimize the regulatory burden on providers as well. 

    AHA said the association "support[s] the health care system moving toward the provision of more accountable, coordinated care" and "believe[s] that programs implemented by CMMI are an important step toward determining the best methods to improve the quality of care while also reducing Medicare expenditures" (Firth, MedPage Today, 11/22; Minemyer, FierceHealthcare, 11/22).

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