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CMMI Requests Ideas to Spur Innovation and Reduce Burden

The Center for Medicare & Medicaid Innovation (CMMI) is seeking ideas on how to better drive change and reduce regulatory burden. CMMI solicited ideas to shape the agency’s future activities through a September 2017 “request for information” (RFI). The RFI is consistent with the administration’s goal to encourage market-driven innovation and may present a significant opportunity for providers and other organizations to shape future changes to the Medicare and Medicaid programs. 

CMMI is accepting ideas and comments from the public through Nov. 20 via an online survey or by email to [email protected]. Listed below are 10 ideas that may be under consideration at CMMI, in areas including:

  • Reducing regulatory burden

  • Promoting alignment across payors and migration to risk

  • Expanding the design of CMMI models

Reducing Regulatory Burden

1. Following recent Congressional deliberations on the effect of the health care fraud and abuse laws on new models of care, stakeholders may advocate that CMMI permit model participants to “self-implement” waivers of applicable fraud and abuse laws. CMMI could move from the use of model-specific waivers that are narrowly crafted by the agency to an approach akin to that used in the Medicare Shared Savings Program (MSSP) under which ACO governing bodies can waive fraud and abuse laws by deciding that an arrangement is “reasonably related” to the program’s purposes. 

2. The Administration has also been focused on reducing regulatory burden, and arguments on how to do so are likely to be well received by the agency. For example, commenters may argue that CMMI’s model application process and materials should be simplified to reduce regulatory burden. In that vein, CMMI could articulate consistent requirements applicable to the models being tested, rather than creating “one-off” approaches for each unique model. Application and participation burden could be reduced through the use of uniform processes, expectations, principles and rules that span different models (i.e., population-health, episodes of care, chronic conditions, care transitions) being tested. 

3. It is likely that stakeholders will focus on the interplay between the implementation of the Quality Payment Program (QPP) and CMMI. We anticipate comments advocating for the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to be given robust resources and authority to test physician-driven Alternative Payment Models (APMs). For example, stakeholders may advocate for a shorter timeframe than the proposed 18-month PTAC review cycle and ask the agency to implement a “fast-track” process and empower the PTAC to test proposals. 
 

Promoting Alignment Across Payors and Migration to Risk

4. The agency may be asked to build on some aspects of the QPP to encourage models and approaches that build on existing structures, align Medicare and Medicaid, and incent timely migration to financial risk. Potential strategies include permitting already existing networks (i.e., CINs, IPAs, etc.) to participate without having to create new entities, adjusting minimum savings rate requirements to encourage participation and increase early-term payouts, and permitting organizations that commit to migrate from pure fee-for-service to risk over a defined time period (e.g., five years) to qualify as Advanced APMs (and therefore make the entity eligible for Medicare payment bonuses). 

5. Further, commenters could urge CMMI to define creative “financial risk” standards for Advanced APMs in ways that couple the requirements of the QPP with pragmatic perspectives of what constitutes “financial risk.” One possible approach would be to permit documented investments in value-based infrastructure (e.g., electronic health records, population health technology, data interfaces, care coordination systems and others) to be considered in APM risk calculations. 

6. The agency may receive queries to consider CMMI-private partnerships to make reinsurance more affordable, and to stimulate other means to migrate from fee-for-service to risk. In that vein, CMMI could help manage the predictability of innovative models, and by doing so, limit potential operational costs and increase involvement. 

Expanding the Design of CMMI Models

7. To allow greater participation in its models, CMMI may be asked to raise caps on gainsharing payments under models such as the Bundled Payment for Care Improvement initiative to permit greater rewards to providers whose care delivery practices drive improvement and change. 

8. Building on stakeholder comments in regard to the QPP, the agency may be urged to adjust approaches to the measurement and use of quality in CMMI models. For example, CMMI could replace scaling of financial rewards that require significant improvements in quality with models that focus on preserving minimum levels of quality or provide rewards for more modest improvements from current performance. 

9. Given ongoing concern about how “cost” is measured by CMS and other payors, commenters may urge CMMI to refocus “cost of care” measures to consider broader cost categories. For example, many commercial value-based and at-risk models include pharmacy costs in the total cost of care as a means to encourage providers to modify prescribing practices. 

10. CMMI is likely to be pressed for models that encourage participation of providers and suppliers across the continuum of care, to include freestanding ambulatory surgery centers, post-acute providers and others. Commenters may argue that the proactive creation of models for such entities would create a more inclusive approach and allow CMMI to gain useful data to assess how collaboration among different provider types can create savings, address quality and drive innovation. 

Provide your feedback and thoughts on the ideas outlined above by taking our survey.

© Polsinelli PC, Polsinelli LLP in California

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Stephen Angelette, Health Care Services Lawyer, Polsinelli Law Firm
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Stephen Angelette recognizes that in today’s ever-changing health care landscape, proactively understanding the business challenges clients face can positively impact their outcomes. He applies his unique understanding of health care issues toward representing hospitals, physician groups, and other health care professionals and organizations in a variety of health care matters. Stephen is able to evaluate arrangements among health care providers to determine compliance with fraud and abuse laws.

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Bruce Johnson, Health Care Organization Attorney, Polsinelli Law FIrm
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Bruce Johnson assists clients with a strategic, forward-thinking and pragmatic approach. He brings more than 25 years of legal and management consulting experience to his health care organization clients. Bruce assists hospitals, medical groups, academic practice plans and other health care enterprises in crafting effective relationships to promote business objectives while taking into account strategic, compensation, business operations, compliance, and other issues in today’s changing payment and delivery environments.

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Gerald A. Niederman, Polsinelli PC, Trade Associations Lawyer, Health Regulation Attorney
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Gerald Niederman is actively engaged in helping clients achieve business and professional success in a legally compliant manner. Representing health care organizations and related nonprofit groups in Colorado and throughout the United States, Gerry works with clients that include hospitals, ambulatory surgical centers, medical groups, trade associations, and related enterprises on matters affecting the delivery and reimbursement of health care services throughout the industry. Gerry's broad knowledge of the federal and state health care regulatory environment and in-...

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Cybil G. Roehrenbeck, Polsinelli PC, Precision Medicine Lawyer, Genomics Attorney
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Focusing on emerging health care sectors, Cybil Roehrenbeck is dedicated to helping clients achieve their objectives by employing a comprehensive, interdisciplinary approach to their legal and business challenges. She counsels clients on federal legislative and regulatory opportunities in the following areas:

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Gabriel Scott, Polsinelli Law Firm, Raleigh, Health Care Law Attorney
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Gabriel Scott has a deep understanding of the evolving health care regulatory environment and the changes occurring at both the national and state levels. Prior to joining Polsinelli, Gabriel spent several years in federal civil service and the private industry. His experience, with both payor and provider sides, allows him to offer a unique perspective to clients’ regulatory and transactional challenges. Gabriel previously worked at the Centers for Medicare and Medicaid Services (CMS), first in the Center for Medicare & Medicaid Innovation (CMMI) and later in the...

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