Wednesday, November 22, 2017

Very Brief Blog: Updated Resources for "Center for Innovation" Reform & New Directions

In September, with a WSJ editorial, CMS Administrator Seema Verma kicked off an open comment period on ways that CMS could adapt and improve the Center for Innovation (aka CMMI).   (Here).

The comment period closed on November 20, and several public comments are available now.
  • The Center for Healthcare Quality and Payment Reform issued a 20 page whitepaper, here.
  • Hospitals:
    • The American Hospital Association made its CMMI comments public in a 17 page letter, here.
    • Federal of American Hospitals, 17 pages, here.
  • Digital: 
    • Healthcare Informatics trade journal, here
    • Electronic Health Record Association (EHRA), 3 pages, here.  
    • American Telemedicine Association (ATA), 4 pages, here.
  • Premier made public a 19-page letter, here.
  • Personalized Medicine Coalition 6-page letter, here.
  • Physicians:
    • Review of physician group comments, at MedPage Today, here.  
    • Internists' viewpoint at MedicalXpress, here.  ACR, here.
  • See a short review at Fierce Healthcare, here.  And at Healthcare Dive, here.  Becker's Hospital Review, here.
    • Blog by Micklos & Wrobel at Health Affairs, here
    • Open access article by David Pittman at Politico, here.
    • I haven't found any consolidated, open access database for all comments.
  • Kaiser Health News says that Canada admires the CMMI, here.
Get the cited public comments in one zip, here.

To my eye, there are three general topics that CMMI should address to speed all its projects.   

First, CMMI has an amazing (an legally un-tested) authority to waive any Medicare law in the process of doing a demonstration.   However, this legal authority seems clearly pointed (to this non-attorney) at only its demonstration authority, not its permanent project implementation authority.  CMS should figure this out and take a clear position. 

Second, Congress allows CMMI to implement permanent projects when they are certified to be cost neutral or cost saving, and quality neutral or quality improving.  From the extremely limited use of this certification process in six years, there don't seem to be clear guidelines as to how certain is certain enough for certification (no model can perfectly predict later costs and outcomes in a nationwide population).

Both the above topics are fundamental to all CMMI model designs, tests, and expansions, and leaving them fuzzy means that the designers and evaluators don't have clear guidelines and guardrails and targets in the business of  planning for and achieving success.

Third, CMMI has always stated it does not intend to test technologies and services, but rather broad schemes like ACOs.  Yet there are all kinds of technologies that fall outside current narrow or dated rules, and this could be a very fruitful use of CMMI projects.  For example, the Diabetes Prevention Program (DPP) has been the first program shifted by rulemaking into a new, innovative benefit, and it's a technology-or-service.  GAO has encourged CMS to look at cost saving new technologies even when they slip outside current benefit structures (here), but CMS poo-poo'd the recommendation.  

It's easy for some projects to be cost-saving and yet be bogged down in Congress for years.   Congress and CBO rated a telehealth expansion (targeted to fixing certain nuances of Medicare Advantage financing rules) as cost-saving for CMS and taxpayers yet it's bogged down on the Hill for several years without passing.  Dumb!   (It might be moving now, by extracting current HR 3727 from a slow moving Senate bill CHRONIC, and then tacking HR3727 onto a pending Medicare Extenders omnibus bill.)  The point is it takes the Hill 3 years or more to pass even an endorsed, cost-saving slam dunk bit of legislation, and CMMI could accomplish this in two hours.