CMS' Center for Medicare and Medicaid Innovation could mandate more participation in its models, CMMI Director Liz Fowler said during a Health Affairs event on Thursday.
The agency wants to ensure that its experiments prioritize patients' needs and support the transformation of the healthcare delivery system—objectives consistent with the Biden administration's greater emphasis on improving health equity and quality. But they also signal that CMMI will fight against the entrenched interests of a healthcare industry under increasing pressure to change the way it does business.
"The system works well for everybody, except sometimes the patients," Fowler said.
Providers, insurers, drugmakers and other healthcare groups benefit when costs and spending increase, but few stakeholders benefit when costs and spending go down, she noted. CMS projects that overall healthcare spending will reach nearly 20% of gross domestic product by 2027.
"That's what we're trying to change," Fowler said.
In addition, more than 90 million people rely on Medicare, Medicaid and the Children's Health Insurance Program for their healthcare coverage, making CMS the largest payer in the U.S.
"No other payer comes close to matching the influence wielded by our agency, and many payers follow our lead. And that means that we are in a unique position to be a healthcare disruptor and a driver for change," Fowler said. "We take that responsibility very seriously."
That disruption could include more mandatory participation in CMMI's experimental models and other changes to encourage providers and commercial payers to rely less on traditional fee-for-service reimbursement and invest more in care coordination and management.
Many experts think that too many of CMMI's models are voluntary rather than mandatory. When the agency first started, the models needed to be optional because neither the center nor hospitals knew how providers or the demonstrations would perform because so few people had experience beyond fee-for-service reimbursement. They believe now that CMMI and providers have a decade's worth of experience under their belts, it's time for the agency to test and expand more mandatory models.
Volunteer models have proven that doctors and hospitals can respond to alternative payment models' incentives. But they're limited since the only providers that participate are the ones that think they'll be successful.
"Voluntary models (are) subject to risk selection, which has a negative impact on the ability to generate system-level savings," Fowler said. "We want to focus on our investments on strategies that are aligned with the overall goal of health system and transformation. We really want to keep our eye on the ball of health system transformation. I think that entails clearing a path for innovators (and) pushing the laggards."
She's hoping to recapture the healthcare industry's lost momentum on the transition from volume- to value-based care, which stalled in recent years because it's relatively easy for most providers to continue practicing fee-for-service medicine.
"The penalties for doing so are really not that great," Fowler said.
CMMI will increasingly require providers and insurers to report more information about health equity to participate in its models and include such information in its quality measures and evaluations.
The agency also plans to design or redesign its experiments to ensure that all communities can participate, not just those with the most resources.
"Not all institutions or organizations have ready access to capital or the technology that might be required to participate in the models. And similarly, our administrative requirements are sometimes too high for some participants," Fowler said.
She hinted that CMMI could focus more on experiments that address the social determinants of health in the future. However, nothing appears imminent as the agency is still reviewing its strategy and model portfolio. And while the agency will continue to adjust for social risk factors in future experiments, CMMI could include more rewards for participants that address and improve their patients' social determinants of health.
"We need to do a better job, and our model participants need to do a better job of forging relationships and working with community-based organizations," she said.
In addition, the agency's experiments will focus more on issues that are important to patients. That might include their ability to perform normal daily activities and greater use of home health and telehealth services through alternative payment models to meet patients where they are.