179 lawmakers say mandatory Medicare payment reforms are illegal

CMMI 'has exceeded its authority,' letter says

A large group of House lawmakers in a letter sent Thursday called on CMS to halt new mandatory payment reforms, which they said go beyond the agency's authority.

Reps. Tom Price (R-Ga.), Charles Boustany (R-La.), and Erik Paulsen (R-Minn.) led the letter, which was signed by 178 House Republicans and one House Democrat. The lawmakers sent the letter to CMS CMO and Deputy Administrator for Innovation and Quality Patrick Conway and acting CMS Administrator Andy Slavitt.

The letter addressed recent payment reforms announced by the Center for Medicare and Medicaid Innovation (CMMI), which was created under the Affordable Care Act.

Lawmakers say CMMI proposals exceed agency's authority

The lawmakers in the letter wrote that CMMI "has exceeded its authority, failed to engage stakeholders, and has upset the balance of power between the legislative and executive branches" by recently:

  • Finalizing he first mandatory bundled payment program for Medicare fee-for-service payments, the Comprehensive Care for Joint Replacement (CJR) model;
  • Proposing a new mandatory bundled payment system for heart attack treatments, the Cardiac Bundled Payment Model; and
  • Proposing changes to how Medicare reimburses physicians for drugs administered under Medicare Part B.

The lawmakers wrote, "Until recently, the tests and models developed by CMMI were implemented, as intended, on a voluntary, limited-scale basis where no state, health care providers, or health insurer had any obligation to participate." However, the lawmakers accused CMMI of overstepping its authority by mandating health care providers' participation in the new proposals, which they argue would "overhaul major payment systems, commandeer clinical decision-making, and dramatically alter the delivery of care."

The lawmakers added, "What makes these proposals even more disconcerting is their potentially negative effects on patients." They wrote that CMMI through the new initiatives is "blindly" forcing Medicare beneficiaries "into high-risk government-dictated reforms with unknown impacts."

The lawmakers argued that "CMMI interprets [its] authority to 'test' innovative models on a limited basis as a means to substantially alter both the delivery and reimbursement of care without any input or approval from Congress and" U.S. residents. They wrote that such large-scale changes should be made via legislation, adding, "Accordingly, we insist CMMI stop experimenting with Americans' health, and cease all current and future planned mandatory initiatives within the CMMI."


Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, said CMS has been implementing new health care models quickly and without feedback from stakeholders, adding that the lawmakers' letter is an appropriate response to that trend.

Halee Fischer-Wright, president and CEO of the Medical Group Management Association, in a statement said she agrees with the lawmakers' concerns, adding, "CMMI must engage in an open and transparent process that incorporates physician input to develop and evaluate new [alternative payment models] prior to mandatory implementation."  She continued, "Instead of a purely top-down government approach, CMMI should also adopt proven private sector initiatives that advance Medicare's goal to provide highly quality, cost-effective patient care."

However, Topher Spiro, VP of health policy at the Center for American Progress, dismissed the letter, stating, "That the Republicans dislike CMMI and the Affordable Care Act is not a surprise." He added, "Sending a letter won't do anything to change the direction or focus of payment reform to lower health care costs" (Muchmore, Modern Healthcare, 9/30; Sullivan, The Hill, 9/30; Price et al., House letter, 9/29; Young, CQ HealthBeat [subscription required], 9/30).

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