Life Science Compliance Update

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November 16, 2017

CMS RFI Issued Regarding CMMI and Payment Models

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In September, CMS issued a "request for information" (RFI) to solicit new ideas that will revamp CMS' Center for Medicare and Medicaid Innovation (CMMI) and the payment models the center creates. Specifically, CMS “is seeking your feedback on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.”

New Model Design

According to the RFI, CMMI will approach new model design with several guiding principles:

  1. Choice and competition in the market – Promote competition based on quality, outcomes, and costs.
  1. Provider Choice and Incentives – Focus on voluntary models, with defined and reasonable control groups or comparison populations, to the extent possible, and reduce burdensome requirements and unnecessary regulations to allow physicians and other providers to focus on providing high-quality healthcare to their patients. Give beneficiaries and healthcare providers the tools and information they need to make decisions that work best for them.
  1. Patient-centered care – Empower beneficiaries, their families, and caregivers to take ownership of their health and ensure that they have the flexibility and information to make choices as they seek care across the care continuum.
  1. Benefit design and price transparency – Use data-driven insights to ensure cost-effective care that also leads to improvements in beneficiary outcomes.
  1. Transparent model design and evaluation – Draw on partnerships and collaborations with public stakeholders and harness ideas from a broad range of organizations and individuals across the country.
  1. Small Scale Testing – Test smaller scale models that may be scaled if they meet the requirements for expansion under 1115 A(c) of the Affordable Care Act (the Act). Focus on key payment interventions rather than on specific devices or equipment.

CMMI states that it is looking to test models in eight focus areas: (1) Increased participation in Advanced Alternative Payment Models (APMs); (2) Consumer-Directed Care & Market-Based Innovation Models; (3) Physician Specialty Models; (4) Prescription Drug Models; (5) Medicare Advantage (MA) Innovation Models; (6) State-Based and Local Innovation, including Medicaid-focused Models; (7) Mental and Behavioral Health Models; and (8) Program Integrity. However, the Innovation Center may also test models in other areas.

New Direction

In August, after delaying several mandatory bundled payment models, CMS ultimately proposed to scale back the Comprehensive Care for Joint Replacement (“CJR”) Model, a bundled payment program for hip and knee replacement implemented by the Obama Administration, and eliminate the Episode Payment Models and Cardiac Rehabilitation Incentive Payment Model scheduled to begin on January 1, 2018.

In a Wall Street Journal op-ed announcing the RFI, Administrator Verma noted the following: “Clinicians, patients, entrepreneurs, state officials and others are busy designing new and better ways to provide health care. There are a lot of great ideas, and we want to hear from people on the front lines. No government agency has all of the answers, especially in an industry as large and multifaceted as health care.”

As has been previously noted, accountable care organizations, hospitals, and primary care providers were not mentioned at all in the RFI. This is a major shift in focus from an agency that once championed these care settings. This lack of inclusion gives one reason to believe that bundled payments will not only continue, but will be underscored as viable paths for physicians’ success under the MACRA alternative payment model track. In addition to a shift in focus of providers, discussion in the RFI of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) initiative, centered on developing physician-driven APMs, indicate that CMMI will much more focused on specialty care and specialty physicians.

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