Publications & Presentations
February 15, 2017
From Inside Health Policy

by Michelle M. Stein

The Healthcare Leaders for Accountable Innovation in Medicare is calling for HHS Secretary Tom Price to stop CMS' innovation center from requiring providers to participate in demonstrations, and a spokesperson for the House Ways & Means Committee says Chair Kevin Brady (R-TX) wants to work with Price on guardrails for demonstrations that test reforms. Republican have tried to kill mandatory demos, but it could be a challenge to pull back the mandatory hip and knee replacement bundle that is already underway, according to some following the issue.

The Affordable Care Act created the Center for Medicare and Medicaid Innovation, and Republicans, including Price, harshly criticized the past administration's use of the center. They've said that Congress should have a greater say in what the innovation center tests and that the center shouldn't be allowed to propose nationwide or mandatory demonstrations.

The Comprehensive Care for Joint Replacement is the only mandatory demonstration that is currently up and running. Near the end of the Obama administration, CMS expanded that demonstration and created a mandatory cardiac care bundle, but that rule has yet to be implemented. CMS also proposed a mandatory demonstration on Part B drug reimbursement, but the agency killed it shortly before the end of President Barack Obama's term.

Despite Price's criticism of CMMI while a lawmaker, when being considered for HHS secretary, he said, "[T]hese authorities can be important ways to ensure there is flexibility in CMS programs and activities for the individual and varying needs of states."

"CMMI is a program providing significant opportunity for testing new models for healthcare financing and delivery," he wrote in response to written questions from Senate Finance Committee members. "I defer to the Congress regarding the funding of the Innovation Center and any ACA repeal and replacement legislation. If confirmed, as HHS Secretary - and if the Innovation Center remains funded - I will ask CMS to pursue models that will lower healthcare costs and improve quality for Medicare and Medicaid beneficiaries."

Tim Gronniger, a former CMS official under the Obama administration, said he's hopeful that because Republicans have previously built on CMMI through the bipartisan law that set up a new Medicare physician payment system, they may continue to do so. It will be interesting to see whether CMMI focuses on the new physician pay system models or if the focus is elsewhere, he said. Josh Seidman, a senior vice president at Avalere Health, said Price has made it clear that Medicare should test new models. He predicted Price's criticism of CMMI during the Obama administration may fade.

A Ways & Means spokesperson told Inside Health Policy that Brady, while concerned about the Obama administration's use of CMMI, looks forward to improving it under Price.

"While the last Administration misused CMMI as a vehicle for imposing its one-size-fits-all health care agenda, Chairman Brady believes that, with the right Congressional oversight and input from stakeholders, the innovation center can help strengthen Medicare. He looks forward to working with HHS Secretary Price, the incoming CMS Administrator, and others in the Trump Administration to ensure the right guardrails are in place to improve the program and protect Medicare beneficiaries," the spokesperson said.

The Healthcare Leaders for Accountable Innovation in Medicare, which is made up of providers, brand drug makers and others, suggested principles for the innovation center: foster strong, scientifically valid testing prior to expansion; respect lawmakers' role in making changes to health policy; consistently provide transparency and meaningful stakeholder engagement; improve data sharing from testing; strengthen beneficiary safeguards and educate beneficiaries about demonstration projects; and collaborate with the private sector.

The coalition says that for testing to be valid, CMMI should have transparent evaluation plans, demonstrations should be appropriately scaled and time-limited and participation in models must be voluntary. The Medical Group Management Association also asked Price in a Feb. 10 letter to make future CMMI demonstrations voluntary.  Gronniger and Seidman said that as Price had raised concerns with mandatory demonstrations, many expect he will give that area another look. However, Gronniger said the CCJR demonstration is already up and running, so it would be challenging to pull it back, especially since doctors get a percent bump in pay for participation in that demonstration and hospitals may be expecting to receive shared savings, as well. Julius Hobson, a senior policy adviser at Polsinelli, said once a demonstration is started, pulling it back could open up CMS to accusations of waste unless the agency could determine a major flaw in the demo's premise.

Seidman said that while it would be challenging to pull the demo back, Price could make adjustments to it through rulemaking, and could also use rulemaking to slow down or change the expansion of CCJR and the cardiac bundle that the Obama administration finalized shortly before leaving office.

Seidman, though, said Price may have more opportunity to test out new ideas in the Medicare program through CMMI than through legislative channels, as there doesn't seem to be a great appetite to make changes to Medicare legislatively. To the extent Price wants to test certain Medicare ideas, CMMI becomes a tool for that, Seidman said, pointing to the possibility of tests on Medicare premium support or ways to examine beneficiary accountability for the costs of care. Gronniger, however, noted that there are specific beneficiary protections that CMMI must take into account when designing any such tests.

Hobson said he believes Price will probably narrow the innovation center's focus, but he said that CMMI changes are likely not high up on Price's to-do list, as he has a lot to handle and a first priority needs to be getting HHS personnel in place.