CMMI Remains Dedicated to Value-Based Care Despite Pause to Some Models, Fowler Says

In addition to providing insurance for the uninsured, the goal of the Affordable Care Act was to move away from fee-for-service to value-based care. Although strides have been made, right now, the Center for Medicare and Medicaid Innovation (CMMI) is taking time to reassess its portfolio of payment models, explained Liz Fowler, PhD, JD, deputy administrator and director of CMMI, during the opening plenary of the NAACOS Spring 2021 Conference.

The past year with the COVID-19 pandemic has revealed some of the US health care system’s limitations, such as vast racial and ethnic disparities and the shortcomings of fee-for-service when volume drops, she said.

However, over the past 10 years, the new companies and organizations that have been created, as well as new models of care and investments in practice transformation, have shown that many parts of the health care system are ready to make the shift to value-based care, Fowler said. In addition, it has become clear that there is a role for CMMI and the alternative payment models (APMs) it produces.

Finally, it has become very apparent that innovation and health system transformation is an iterative process. In order for CMMI’s APMs to succeed, the center may sometimes speed up when there is an opportunity but might need to slow down and reassess a forthcoming model to ensure it will work as intended.

Fowler acknowledge that some of CMMI’s models have been put on hold as the center continues to review them. Among the models that have been paused are the Primary Care First’s Seriously Ill Population component and the Geographic Direct Contracting Model. In addition, the start dates for Kidney Care Choices and the Community Health Access and Rural Transformation accountable care organization have both been delayed.

“I understand that collectively these announcements may have led to questions about where the center is headed next. I want to make clear that our commitment to value-based care has never been stronger,” Fowler said.

CMMI wants to make sure that its models lower costs, improve quality of care, and better align payment systems to promote patient-centered care, she added. Not every model will be a home run, and when things don’t work, CMMI needs to be agile.

“True innovation means failing until we get things right, and it’s just as important to learn from what doesn’t work and be transparent about those findings, so we can continue to refine, evolve and grow,” Fowler said.

Fowler worries that over the last decade since CMMI was established, there is not consensus among the stakeholders about what should be achieved. Some of the questions that need to be answered are:

• Are cost savings the most important measure of success, or is quality improvement just as important?
• Is risk bearing among providers the key to unlocking value?
• Should CMMI’s goal be to expand a model so it becomes a permanent part of Medicare or is health care transformation the ultimate goal?

“I want to take a look at these questions and think about the bigger picture issues and focus on longer-term health system goals,” she said.

Fowler then took time to outline the coming months at CMMI. She and senior leadership are working to implement a plan based on shared priorities, such as advancing health equity. Every stage of CMMI’s models—model development, participant recruitment, model evaluation, etc—should take into account health equity. The center is also working with HHS Secretary Xavier Becerra and the Biden health team on their key priorities, including prescription drug pricing.

She concluded by reiterating that the current administration is committed to not only expanding access to health care, but also moving the system toward value. The country’s health system is “at a crossroads” and needs to draw on the lessons from the past 10 years to chart a path forward, she said.

“I'm asking for your help in charting this path forward to getting back to a place where we have common goals and a shared vision,” Fowler said. “And I'm asking for your patience as we take time to review the portfolio of models, make adjustments where necessary, and make sure that our path forward is sustainable and meaningful.”

In a following Q&A with NAACOS President and CEO Clif Gaus, ScD, Fowler dug more into the competing APMs in the US health system. Gaus noted that models have changed to become more complex, and it can be longer before an evaluation identifies how well the model is performing.

Fowler said that there have been recommendations to do fewer models and concentrate in certain areas to combat how complex the landscape has gotten with overlapping models. Until now, there has been a lot of work toward the certification of models in order to become a permanent part of Medicare, but it’s not easy to get the model certified.

“I wonder if we can think instead about models, the overall goal being transformation of the system, instead of certification, or both,” she said.

They brought the conversation back to health equity and how to advance that goal. According to Fowler, health care providers need to collect, report, and use data on race and ethnicity, and this will be a part of models being developed going forward. In addition, CMMI needs to develop, test, and scale models that reduce disparities, and she called on the attendees to let the center know if they have seen models that work.

“Health systems can certainly do more to help address racism in our health care system, in their policies and programs and meaningfully engage communities,” Fowler said. “And, you know, we also need to think about the health care workforce and having a more diverse workforce. So, there's a number of elements to this problem.”