The Affordable Care Act and the Medicare and CHIP Reauthorization Act (MACRA) provided the Centers for Medicare and Medicaid Services (CMS) with tremendous authority, by creating the Center for Medicare and Medicaid Innovation (CMMI). With the recent election leaving the executive and legislative branch in the hands of the Republicans, depending on who you ask, the future of that authority is in question.
CMMI was created under the ACA to test innovative payment and service delivery models to reduce program expenditures and improve health care. To meet that goal, the ACA allows CMMI to waive any Medicare provision of the Social Security Act, in addition to select Medicaid provisions, that may be necessary to carry out and evaluate demonstration policies. If the demonstrations prove effective, CMS may roll out the program nationally.
CMS has implemented numerous demonstration projects under CMMI’s authority over the past few years, including delivery reform demonstrations such as the Medicare Shared Savings Program and Pioneer ACO program, and the Financial Alignment Initiative (a program that integrates care for dual-eligible individuals in select states).
Demonstrations such as the Medicare Advantage Value-Based Insurance Design Model have focused on encouraging the use of high-value clinical services, while others, such as the Diabetes Prevention Program, focused more on preventive service models. In July 2016, CMS proposed expanding the Diabetes Prevention Program nationally.
Giving credence to the concerns of those who believe the future of CMMI authority hangs in the balance is the nomination of Representative Tom Price as Health and Human Services Secretary in the Trump Administration. In September 2016, Representative (and physician) Tom Price sent a letter to CMS condemning CMMI’s large mandatory demonstrations, stating that “CMMI has exceeded its authority, failed to engage stakeholders, and has upset the balance of power between the legislative and executive branches.”
Congressmen and women who signed off on the letter were concerned about the “potentially negative effects on patients, especially our vulnerable seniors” that the proposals made by CMMI may have. The letter insisted that “CMMI stop experimenting with Americans’ health, and cease all current and future planned mandatory initiatives within the CMMI.” Additionally, the letter requested CMS “commit to ensuring future CMMI models fully comply with current law.”
The letter, signed by roughly 150 members of Congress, specifically references the Cardiac Bundled Payment Model, the Comprehensive Care Joint Replacement Model, and the Part B Drug Payment model as problematic programs. The House Budget Committee also held a hearing criticizing the authority granted to CMS and CMMI, effectively usurping the role of Congress in creating public policy. They noted that by “focusing solely on cost-savings without adequate regard to the detrimental effects that the CJR Model, Part B Drug Payment Model, and Cardiac Models may potentially have, CMS at best has heeded only part of its statutory duty – “reduc[ing] program expenditures” – at the expense of its other duties – “preserving or enhancing the quality of care.”
Those who signed the letter also took issue with CMMI failing to meet its statutory requirements for implementing models, including starting with a limited, “Phase I” test, engaging stakeholders in model development, and describing the “defined population” and “deficits in care” the model seeks to address.
With new nominees and news coming out daily about various focuses of the Trump administration, it is possible that CMMI (and perhaps other programs) will soon be eliminated or modified.