A rarely mentioned entity that was created by language in the Affordable Care Act (ACA) is the Center for Medicare & Medicaid Innovation (CMMI), housed within the Centers for Medicare & Medicaid Services (CMS). The Innovation Center’s principal task is, as its title declares, to develop and test innovative healthcare payment and service delivery models with the goal of lowering costs through improvements to the healthcare system. As an example of this, CMMI has played a critical role in implementing the Quality Payment Program (QPP), which Congress created as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Policy changes can come about outside of the congressional legislative process through the creation and implementation of regulations, something that the current administration is looking to utilize via the CMMI to reintroduce a Medicare reform model long favored by Republican policymakers.
In a “premium support model,” as it is commonly known, the federal government would provide a payment on behalf of each Medicare patient toward the purchase of a health insurance plan – either a private plan, a similar Medicare Advantage plan, or traditional Medicare. Under this system, health plans would compete for enrollees and people on Medicare would choose among plans for their coverage, as they currently do, but with the key difference that payments for services provided would be capitated rather than the current approach of tying payments to the specific services that patients use. This method has also been called a defined contribution or a voucher approach. (It is important to note that the capitated payment would be to the health plan and not the physician who bills Medicare directly. Physicians and physician groups who bill Medicare are under QPP regulations).
This idea is not entirely new, as it has made prior appearances as far back as 2011 in multiple legislative proposals by senators such as Lindsey Graham (R-SC), Richard Burr (R-NC), Tom Coburn (R-OK), House Representative Rand Paul (R-KY), and most recently in policies outlined in Speaker Ryan’s “A Better Way” plan in 2016.
The Health and Human Services Department (HHS) is beginning to set its policy agenda for CMMI after presenting a proposal on September 20 seeking input from stakeholders on various ideas such as premium support, physician private contracting with patients and balance billing, and value-based purchasing contracts for prescription drugs. Stacy Sanders, federal policy director at the Medicare Rights Center, said she is “concerned about the proposals whether or not they fit the requirements laid out in the statue authorizing CMMI. A model has to either save money and maintain the same or better level of care quality, or keep spending neutral and improve quality.”
For information on the CMMI, visit https://innovation.cms.gov/initiatives/direction/.
Gabriela Villanueva is CAP’s Public Affairs Coordinator. Questions or comments related to this article should be directed to gvillanueva@CAPphysicians.com.