Concerns over the role of the Center for Medicare & Medicaid Innovation could lead to legislation intended to hinder the agency and slow its attempts to further the goal of paying providers for value rather than volume.
While no specific legislative language has surfaced, multiple sources confirmed that Republicans upset with what they say is overreach by the CMS Innovation Center, also known as CMMI, are considering a legislative response. A few Republicans have previously said they would support repealing the agency entirely or zeroing out its budget. More modest efforts could include banning mandatory participation in payment models.
Provider groups such as the American Hospital Association and the Medical Group Management Association have also criticized the pace of new payment models being rolled out and said there should be more provider input.
A spokeswoman with the main drug industry lobbying group, which has opposed several demonstration projects, said she couldn't comment on the group's efforts.
“It is clear the CMMI has a level of unchecked authority that warrants further examination and action,” said Allyson Funk, senior communications director for the Pharmaceutical Research and Manufacturers of America.
Acting CMS Administrator Andy Slavitt has aggressively defended the CMMI and said it is key to achieving the bipartisan goal of paying for healthcare services based on value and quality.
Slavitt has explained the CMMI as a conduit for taking what doctors say is working for them in the field and then scaling them for wider implementation. The CMS seeks feedback on the models with outreach to various stakeholders. Pharmaceutical companies have not been responsive, he said.
More than 170 House Republicans sent a letter to Slavitt in September asking that the CMMI stop requiring mandatory participation in any payment models. They said the agency has upset the balance between the executive and legislative branches by overstepping its authority and failing to engage stakeholders.
“As a result, Medicare providers and their patients are blindly being forced into high-risk government-dictated reforms with unknown impacts,” they wrote. “Any true medical experiment requires patients' consent. However, patients residing in an affected geographical area will have no choice about their participation.”
Joseph Antos, a fellow at the conservative American Enterprise Institute, testified before a congressional hearing earlier this year that CMMI's models were different from those he oversaw while director of the Health Care Financing Administration's counterpart to the CMMI, called the Office of Research and Demonstrations. (The HCFA was later renamed the CMS.)
Those earlier models were all short-term, budget-neutral and voluntary. The CMMI now has more authority and flexibility than has been typical of regulatory actions taken by executive branch agencies, he said.
“That constitutes a fundamental shift from Congress to the executive branch in the ability to set policies for some of our nation's most important and costly public programs,” he said in prepared testimony.
The CMMI was created by the Affordable Care Act in 2010 to test different strategies for promoting quality of care while also reducing costs.
Tricia Neuman, senior vice president at the Kaiser Family Foundation, said the agency “hit the ground running and has been moving at a rapid pace to test different models.”
Some of the models, particularly those that have mandatory provider participation, have encountered significant opposition, she said.
Those include two bundled-payment models—the Comprehensive Care Joint Replacement Model and the Cardiac Bundled Payment Model. The pharmaceutical industry has attacked the Part B Drug Payment Model, which changes how doctors are reimbursed for outpatient drugs.
Neuman said adequate participation in models is needed to properly evaluate whether they're working.
“It's hard to get conclusive results without a sufficient number of participants,” she said. “So there's a balance to be achieved in testing new models in a way that will produce enough evidence of results.”
Some demonstration projects that have shown good results in healthcare settings have been successfully scaled up. Hospital payment methods and coordinated care for those eligible for both Medicare and Medicaid are examples, Neuman said.
Some lawmakers have said the Congressional Budget Office estimates for CMMI models are likely to be inaccurate because of all the unknowns regarding how models would be implemented nationwide and the ways in which the models overlap.
“What is sometimes overlooked is that any assessment of the spending impact of a CMMI demonstration project is not a simple accounting exercise,” Antos said in his testimony. “Whether provided by the CMS actuary or by the CBO, such an estimate is a projection of future program savings based on limited data and modeling assumptions that themselves are based on limited information.”
The CBO has stood by its analyses but agreed they can be complex.
“The CBO monitors the entire CMMI process, from the collection of ideas for new models through the testing, refinement, and evaluation phases of models selected for testing,” officials wrote in a recent blog post. “As the CMMI program matures, the CBO also will monitor expansion decisions and the implementation of those decisions, updating projections to account for those decisions.”
Because the CBO has shown the models are likely to result in eventual cost savings, repeal of those models or the CMMI entirely would be difficult.
