During a recent House of Representatives Energy and Commerce subcommittee hearing, the Center for Medicare and Medicaid Innovation (CMMI) became a hot topic of conversation. Representatives at the hearing were questioning the CMMI’s progress in moving the health care industry towards a value-based care model, particularly in light of a Congressional Budget Office (CBO) report that found that CMMI has actually increased federal spending – not decreased it.
CMMI was created by the Affordable Care Act and is focused on testing new healthcare delivery and payment models, with the intent to lower costs and improve quality in government health care programs. The CBO report, however, found that CMMI’s activities increased direct spending by $5.4 billion from 2011 to 2020 and is projected to increase net federal spending by $1.3 billion from 2021 to 2030.
So far, CMMI has run more than 50 tests of different models, impacting more than 41 million patients and 314,000 providers. However, of those test runs, only six models have generated statistically significant savings and only four were certified for expansion. Elizabeth Fowler, deputy administrator and director of CMMI, noted that one of the challenges to achieving cost savings is that the models are voluntary. Fowler noted that “When you have a voluntary model where providers can come in if they think the terms look favorable, if they can exit if they think the terms may turn against them or they weren’t performing as well as they thought, they can drop out of the model.”
During the hearing, Representative Kim Schrier of Washington raised concerns about which models are certified for expansion, saying, “I’m concerned about CMMI’s current standards for program expansion, and whether they might be too rigid and even prohibitive.” Schrier referenced the Medicare Care Choices Model, which showed cost and quality improvements but was not selected for expansion. Fowler commented that while the Medicare Care Choices Model did reduce net Medicare spending and decreased inpatient admissions and outpatient emergency visits, it did not meet the prescribed standard for being able to be generalized across the patient population.
Fowler noted that while the majority of the models implemented by CMMI have not been certified for expansion, CMMI does learn from every model and the lessons learned are incorporated into future models. Fowler also discussed the strategic direction for CMMI, which was updated in 2021. Part of that strategy is remaining in contact with participating providers and discussing what did not work when they opt to exit the models.
Under the strategy refresh announced in 2021, CMMI has a renewed focus on equity and enrolling more Medicare and Medicaid beneficiaries in accountable care arrangements. Additionally, in 2023, the CMS Innovation Center performed a retrospective review of some of the attempted models to “help inform a new framework to accelerate transformation” that will “aim to more systematically evaluate care delivery strategies that support transformation for providers and patients and to disseminate best practices so that all Americans can access effective, person-centered care.”
“I think we’re really trying to be more transparent in the way that we conduct our business. Trying to signal where we’re going next is the point of the strategy refresh that we put out in 2021,” Fowler said. “And really just generally trying to be good partners for the providers who are out there and make sure that we’re reflecting their input in our work going forward.”