Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

House Reps Urge CMMI to Cease Mandatory Payment Reform Models

Nearly 180 House representatives contended that implementing compulsory CMMI payment reform programs oversteps the agency’s authority.

By Jacqueline LaPointe

- In a recent letter to CMS leaders, House representatives urged the federal agency to stop all mandatory payment reform demonstrations through the Center for Medicare and Medicaid Innovation (CMMI), such as the ongoing Comprehensive Care for Joint Replacement program as well as the upcoming Cardiac Bundled Payment and Medicare Part B Drug Payment models.

The representatives contended that CMMI overstepped its legislative authority by implementing compulsory, nationwide alternative payment models without Congressional approval. The federal agency also neglected to gather stakeholder feedback on the three compulsory alternative payment models, and failed to determine if the large-scale programs would maintain or improve quality of care.

“This [the proposed CMMI models] would be a step backwards in our unified effort to move to higher quality, more value-based care for our nation’s seniors,” stated the letter. “We ask that you cease all current and future planned mandatory initiatives under the CMMI.”

CMMI, until recently, used to test payment reform models on a voluntary basis, and no state, provider, or payer was required to participate, the representatives explained. But in November 2015, CMS released the final rule on the Comprehensive Care Joint Replacement model, which required at least 800 hospitals in 67 geographical areas to take part in Medicare bundled payments for hip and knee replacements.

In 2016, the representatives added, CMS proposed the Part B Drug Payment program, which would reimburse Medicare providers for prescription drugs under an alternative payment model, and the Cardiac Bundled Payment model that would require one-quarter of all metropolitan areas to participate in bundled payments for certain cardiac episodes as well as expand the Comprehensive Care Joint Replacement Model to include more hip episodes.

The CMMI models “overhaul major payment systems, commandeer clinical decision-making, and dramatically alter the delivery of care” without stakeholder input and care quality tests, the letter stated. The authoritative encroachments demonstrate the federal agency’s commitment to reduce healthcare costs even at the expense of quality improvement.

But even the federal agency’s cost-cutting goals may be stymied by large-scale mandatory payment reform demonstrations that do not go through a limited-scale testing phase, the letter argued. A 2015 Congressional Budget Office blog post indicated that some CMMI demonstrations did not yield significant healthcare savings.

“We are aware that some models tested under demonstration programs fail to produce quality improvements and anticipated cost savings,” wrote the representatives. “This is why the statute authorized the Secretary to ‘test innovative payment and service delivery models’ – not mandate them for all providers in designated geographical areas. CMMI’s mandatory models ‘experiment’ with thousands of patient lives without prior testing on a smaller scale or even a basic indication that they will actually achieve improved quality, or, at the very least, maintain present quality.”

Additionally, the representatives stated that CMMI failed to comply with statutory requirements for implementing payment reform models, including a limited ‘Phase I’ test, collecting stakeholder input in model development, and describing the affected population and care delivery gaps the models are expected to address.

“As a result, Medicare providers and their patients are blindly being forced in high-risk government-dictated reforms with unknown impacts,” the letter stated.

To resolve the issues, the representatives called on CMMI to “alter, delay, or upend these mandatory demonstration programs.”

They also asked the federal agency to comply with current laws when developing and implementing future payment reform models, such as limiting the scope of the demonstrations, receiving Congressional approval for model expansions when they require statute changes, and developing a transparent process that promotes communication with providers, patients, and healthcare stakeholders.

Dig Deeper:

Understanding the Value-Based Reimbursement Model Landscape

How to Overcome the Challenges of Bundled Payment Models


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