Friday, August 13, 2021

Where is CMMI Going? Health Affairs Video and Article (Brooks-LaSure)

One key question for the future of CMS is where it will go with the Center for Innovation (CMMI).  On Thursday, August 12, 2021, Health Affairs posted a detailed article on the future of CMMI, by CMS authors, and held a one-hour webinar, archived on YouTube.

See the article here:

See the video at YouTube here:

There are a few strange things about CMMI.   In the Obama administration, Republican senators were eager to kill it entirely, believing it was too powerful.   The Trump administration put CMMI on hold at first, but then realized it was a very powerful tool.  For example, the Trump administration, in its last quarter, proposed resetting US drug prices to European drug prices as a "demonstration project" nationwide for years, under CMMI's authority.  That authority allows CMMI to hold a "demonstration project" of unlimited scope and scale and waiving any part of Medicare law for the duration of the project.   (Yowza!)   Numerous Medicare waivers occur under CMMI authority, but are simply referred to as 1115A waivers, as if it was part of Medicaid protocols rather than the referring to CMMI's blanket authority.

CMS has never conducted regulatory rulemaking under 1115A, so it has been treated was "self-implementing," giving CMS even more "flexibility."   

CMS Article

In the article, CMS highlights six goals for CMMI.

  1. Every Model should include health equity factors.
  2. Don't make too many models.
  3. Design meaningful financial incentives.
    1. They may want to downplay voluntary models, as providers will opt in for profit and opt out to avoid loss, making the model pointless.
  4. "Providers find it challenging to accept downside risk."  
    1. With thin margins, obviously.  "Show strong consistent signals of where CMS is heading for value based care."
    2. I would add, there is also a significant problem with 'rich get richer, poor get poorer' outcomes.
  5. Effectiveness have been limited by faulty benchmarks.
    1. For example, national benchmarks may be out of whack for some systems, but local (individualized) benchmarks may create the wrong incentives.
  6. Success means: lasting transformation of the health system.

Another example of "self implementing" CMS authority has been its authority to conduct medical reviews and audit or recoup from providers. In this summer's PFS rulemaking, CMS proposed to convert some of that statutory authority into regulations for medical review functions, even though those functions have been carried out under "self implementing" authority for decades.


An unofficial auto-transcript from the YouTube link is here.