Q&A: What could a ‘new direction’ mean for CMMI’s payment reforms?

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The new administration at CMS and HHS has signaled it wants to take a different path on value-based care models. Some have been clear actions, like ending mandatory bundled payment models in cardiac care. The next step may be more driven by stakeholders, as CMS recently released a request for information (RFI) asking what new models developed by the Centers for Medicare and Medicaid Innovation (CMMI) should look like.

Archway Health CEO Dave Terry correctly predicted the new leadership would move to voluntary programs. With healthcare organizations now being asked for requests on future models, HealthExec checked in with Terry and Archway’s general manager of Bundled Payments for Care Improvement (BCPI), Keely MacMillian, MSPH, to see where they think this new direction will take CMMI.

What kinds of ideas do you expect healthcare organizations to submit to CMS?

Dave Terry: The RFI itself is interesting. It’s a very broad audience. Anyone can respond. It’s hard to know what different constituents like the (American Medical Association) or the (American Hospital Association) are going to submit.

What’s most interesting to us is while they put this out pretty broadly, they had eight pretty specific priorities. Those priorities seemed to be around physician-driven models, MACRA-related activities and market-based innovation. This is one of the first big things we’ve seen from CMMI under the new administration. It seems like they’re getting their footing now and they’re identifying what they want to focus on.

It does seem a good bit different than what CMMI was focused on previously. They’re very interesting priorities and I think it will spark a lot of interest and a lot of input.

What Obama-era CMMI ideas do you expect providers to be more than happy to do away with?

Keely MacMillian, MSPH: Reporting requirements. The administrative burden around reporting requirements I think has really strapped a lot of practices and hospitals. Meaningful Use is sort of considered to be a disaster in terms of implementation. Ultimately, it hasn’t been a value add, hasn’t really benefitted patients more than it inhibited providers from providing better care. I think taking lessons learned from Meaningful Use and the requirements and trying to get away from that and let doctors spend more time with their patients and not sit in front of a computer screen.

Assuming the future models which come out of this new direction are all voluntary participation, does that limit how successful they can be?

Dave Terry: We actually believe the opposite. What we saw with the mandatory models is not very high engagement from the participating hospitals and really watered-down rules to make it palatable. It just really didn’t move the needle on improvements. The voluntary ones, you see tremendous engagement from the physicians and providers, you see them moving the needle quickly and effectively, and that starts to change markets. You don’t need that many participants to wake up the competition and start moving towards improvement. We actually think the voluntary ones will change and shape markets faster than the watered-down mandatory ones.

Keely MacMillian, MSPH: On the voluntary programs, the ones who opt in to participate are probably the more innovative and creative and solution-driven practices which want to find new ways to be more efficient. I think CMS wants to target those practices versus having hospitals forced into something they don’t want to do.

Are there practices who will view this new direction as a way to go back to their old fee-for-service ways and leave behind value-based care?

Dave Terry: Maybe the fat, happy and slow ones. That’s a glib but sincere comment. We saw in BCPI when that first started in 2011, there was a fair amount of inertia, but once the data became available and innovative and motivated providers saw the opportunity, they jumped in and they’re doing really, really well. They’re getting more control over the process, more autonomy and they’re making more money.

You can try to put your head in the sand and wish it would go away, but it’s not. You put yourself at a competitive disadvantage if you don’t get the data, understand your performance and understand how you compare with others in your market.

Keely MacMillian, MSPH: I do think this new administration, whether they might have a different approach or just a different name, they do genuinely want to get rid of waste in the system and reduce unnecessary federal spending. Regardless of who you are, I think there is a need to reduce excess spending by Medicare and redirect those funds is universally recognized.

The RFI didn’t mention accountable care organizations, hospitals or primary care physicians. What should those providers make of being left out of the talk about this new direction?

Dave Terry: We noticed that too. There has been a shortage of qualifying, advanced (alternative payment models) for specialists, while there’s no shortage for PCPs. It also mentions a desire to promote or enhance the viability of independent specialists and physicians and these models will help do that. I think they have some concern around consolidation and we’ve seen ACO models drive consolidation of primary care physicians and merging them into large health systems and I think they’re wary of that with the ACOs. There may be a little of a de-emphasizing of those models and heavier emphasis on specialty-driven models that independent physicians can participate in.