Upon taking office, Price acted quickly, rolling back impending mandatory orthopedic and cardiac bundled payment programs. In September 2017, new CMS Administrator Seema Verma posted an op-ed in the Wall Street Journal announcing a new direction for CMMI. The administration planned to re-orient CMMI around provider flexibility, free market principles and consumer choice and solicited stakeholder feedback through a request for information (RFI). Later that same month, however, Price was forced to resign, replaced by pharmaceutical executive Alex Azar. In his nomination hearings, Azar struck a decidedly different tone in relation to CMMI, asserting that models may have to be mandatory in some instances to garner adequate data.
In April 2018, Azar appointed Landmark Health CEO Adam Boehler as CMMI director. The two officials have signaled that the center will become more active in both soliciting and managing test models, prioritizing those that will have immediate impact on health care consumers. In particular, CMMI will likely have a role in revising rules around Medicare Accountable Care Organizations (ACOs) and a new, somewhat vague “direct provider contracting” model. This is likely, despite continued discussion around larger administration spending cuts including some $800 million in CMMI budget cuts for 2018 and 2019 (CMMI will receive a new mandatory appropriation renewal in 2020). As of the writing of this article CMMI has 39 active innovation models and five more under development.
Despite more than seven years of operation, the evidence from CMMI is mixed at best. Some of this is intentional; many models have only been in operation for a few years and are meant to take four to seven years before being reviewed for expansion. Most models have shown some degree of cost savings, although few have seen enough savings to offset commensurate management or administrative spending increases. Proponents will say that this is just an indication that models take time to refine as payers and providers realign practice and administration along value-based lines.
From a budgetary standpoint, the Congressional Budget Office (CBO) has consistently projected that CMMI will generate net savings in the long term, most recently projecting $45 billion in savings to offset $12 billion in spending 2017–2026. Many have noted that even without these projections, $1 billion per year for CMMI is a drop in the bucket compared to the roughly $3 trillion spent per year on health care. Some of the specific models have shown financial promise as well, such as the risk-bearing ACO models and the hip/knee replacement outpatient payment bundle. Despite this, just two models—the aforementioned Pioneer ACO Model and the Medicare Diabetes Prevention Program (DPP) Model—have met the PPACA criteria for expansion.
As previously mentioned, the next battleground for CMMI will be regarding voluntary versus mandatory implementation of models. A new study from the University of Pennsylvania examined hospitals that participated in the voluntary BPCI model against those participating in the mandatory Comprehensive Joint Replacement (CJR) model. Researchers found that although the two programs engaged different types of hospitals (voluntary hospitals tended to be larger and higher-volume), there was no difference in baseline spending, quality of care or risk assumed. It is likely that hospital and physician groups will push back against any new mandatory programs. Whether Azar or Boehler will reinstate any remains to be seen.