The CMS Innovation Center Moved the Needle on Value

We should keep this "national treasure" in case of ACA repeal

As Republicans in Congress threaten to repeal the Affordable Care Act, we keep hearing that value-based care is safe. But how safe can it be if we also dismantle the organization behind CMS’ progress and momentum? The Center for Medicare and Medicaid Innovation (CMMI) was created under the Affordable Care Act and is tasked with developing and testing new payment and service delivery models, assessing results, and working with stakeholders to develop additional models. Free from direct Congressional oversight, the CMMI has been remarkably agile, unique in its ability to quickly make changes based on results and feedback from patients and providers.

Photo by  WBEN-TV  via  Flikr

Photo by WBEN-TV via Flikr

CMS and the CMMI have been criticized by Tom Price, Trump's nominee for HHS secretary, for overstepping their boundaries with innovative programs like mandatory bundles for joint replacement. In a letter to the agency last year, he protested mandatory bundles by accusing CMS of “experimenting with Americans’ health.” This claim ignores voluntary bundled payment programs such as 2013’s Bundled Payments for Care Improvement (BPCI) initiative, as well as the processes in place at the CMMI. Although successful models, like bundled payments for joint replacement, may eventually affect policy nationwide, participation in untested models is entirely voluntary. Organizations must apply to participate and are chosen by the CMMI and its stakeholders in an open, competitive process. Only when a model has been tested can the HHS secretary implement it on a wider scale.

Value-based reimbursement has also been criticized for dismantling the patient-provider relationship. The evidence for this is shaky at best. We know that patients report higher satisfaction when their physician performs more tests. That’s fine, but more labs don’t lead to greater insights and don’t signify that the physician cares more. Furthermore, higher spending does not necessarily correlate with better outcomes. Luckily, the patient-provider relationship and value-based care are not a zero-sum game; in fact, patient engagement is often a strategy for providing high-value care. If we return to a fee-for-service structure in which the physician is rewarded for ordering as much of whatever they want, we return to a system that is inefficient and broken. Resisting value-based care is not really about the patient-provider relationship; it’s about resistance to change.

If Congress repeals the Affordable Care Act, it will also disband the CMMI, which will effectively slow down the transition to value-based reimbursement. This will derail not only mandatory bundled payments but also many other models being tested by the CMMI, such as Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMHs), and models focused on prevention or population health. Some of these models, like bundled payments, are suited for short-term success, and have already proven their worth. Others, like ACOs and prevention-based models, are much more slow-moving because they rely on systemic, rather than limited, change. Rolling back these changes before they have a chance to succeed would be an enormous mistake and frankly a waste of tremendous resources. I remember Andy Slavitt commenting that the “CMMI is a national treasure.” High praise from someone who knows. 

If we agree that value-based care is a good thing (we should), we must also agree that the CMMI is a critical organization (it is). Who else is testing a wide range of models and can make changes quickly when something isn’t working? Who else is working closely with providers across the country to ensure that their concerns are addressed? The transition to value-based care has bipartisan support, so dismantling the organization that makes it run is a pointless move that makes me wonder what our goals are. Price needs to take a hard look at the situation and decide if he’s here to help or hurt.