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After 5 Years, CMMI Touts Successes, Lays Out Plans for Payment Models, Managed Care Collaboration


The authors discuss the success of the Pioneer ACO model and the Comprehensive Primary Care Initiative, among others. They outline an agenda that includes engaging managed care stakeholders, so that both public and private payers are moving toward value-based payment.

Authors from CMS’ Center for Medicare and Medicaid Innovation (CMMI) today offered their own review of the agency’s impact after 5 years, in a commentary that appears in the New England Journal of Medicine.

The self-assessment, which also outlines the agency’s short-term agenda, comes from Rahul Rajkumar, MD, JD, CMMI deputy director; Matthew J. Press, MD, senior advisor to the CMMI director; and Patrick H. Conway, MD, deputy administrator for Innovation and Quality and CMS chief medical officer.

The call for payment models that reward care based on value, not volume, was outlined in the 2010 Patient Protection and Affordable Care Act (ACA). That law also created CMMI as a vehicle to test models before they would be implemented on a widespread basis. The authors note that CMMI had a $10 billion appropriation for the years 2011 to 2019, which means the agency’s fate rests with the next president.

CMMI’s reform agenda covers Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), and the authors write that its 26 models cover acute, post-acute, primary, and specialty settings across all 50 states.

They note that successful models at CMMI—those shown to reduce costs without reducing healthcare quality, or shown to increase quality without increasing costs—can be implemented by the US Health and Human Services Secretary through rulemaking. While the authors are not explicit, this is the source of CMMI’s power: the potential exists to create widespread change within Medicare and Medicaid without approval from Congress.

This month, the authors note, the Pioneer ACO model became the first such model to meet that bar—despite the fact that only 19 of the original 32 Pioneer participants remain with the program. The Pioneer model’s mixed record was nonetheless counted among CMMI’s successes, with the authors citing $184 million in Medicare savings and $385 million in risk-adjusted savings its first 2 years.

Expanding the Pioneer ACO model will require changes within CMS itself. Observers have noted that widespread payment reform, and the anticipated rulemaking for Medicaid managed care, cannot happen unless CMS updates the way it does business. The authors acknowledge this, but say the change will also require “a fundamental shift in the clinical operations of US healthcare providers toward population health management.”

They also discuss the Comprehensive Primary Care Initiative, which pays primary practices monthly management fees and has been shown to trim 2% from traditional Medicare Part A and B costs, which more than covers the fees. While the authors do not say so, CMS notably created a new fee starting in 2015 that pays primary care practices approximately $41 per patient per month to coordinate care for Medicare beneficiaries with multiple chronic conditions.

They do note the major shift that is underway, unveiled by HHS Secretary Sylvia Mathews Burwell in January. CMS will require that 30% of all Medicare payments be tied to value-based models by 2016, with that share rising to 50% by 2018. That climb seems steep, except, the authors note, when one considers that today’s share is 20%, and in 2011 it was zero.

What’s ahead for CMMI? The authors highlight 3 priorities:

· Development of new payment models, such as the Oncology Care Model unveiled in February 2015, which is just now accepting letters of intent.

· Partnerships with stakeholders across managed care, including commercial insurers, to promote value-based payment to providers, purchasers, and consumers.

· Sorting out winners and losers. CMMI will begin to expand those models that are working and phase out those that aren’t.

“The Innovation Center will continue working to contribute to US achievement of the goals

of better care, smarter spending, and healthier people,” they write.


Rajkumar R, Press MJ, Conway PH. The CMS Innovation Center—a 5-year self-assessment [published online May 21, 2015]. N Engl J Med. 2015; DOI: 10.1056/NEJMp1501951

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