CMS estimates 41.5M people affected by innovation center models since late 2020

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Dive Brief:

  • More than 41.5 million people have been impacted by or received care in CMS innovation center models in the past two years, according to a new estimate from the agency.
  • That includes Medicare and Medicaid beneficiaries, along with people with private insurance in multi-payer model tests, according to the CMS Innovation Center’s biannual report to Congress covering October 2020 through September 2022.
  • During that time, the CMMI operated 33 models studying potential improvements in healthcare payment and delivery.

Dive Insight:

The CMMI was founded more than a decade ago as part of the Affordable Care Act in an effort to move the needle toward paying for quality instead of quantity in healthcare.

However, few of the center’s models have resulted in cost savings or better quality of care, causing a bipartisan group of legislators to advocate for more oversight of the agency more than two years ago. Over its tenure, the CMMI has tested more than 50 models, but only four have met the criteria for expansion and gone on to permanently become part of Medicare.

Since the CMMI’s inception, six model tests have resulted in statistically significant savings, and two of those models also showed significant improvements in quality. Several models have shown improvements in quality that generated gross but not net savings, so don’t meet the criteria for expansion, according to the new report. 

The CMMI is currently undergoing a strategic revamp to focus more on equity, falling in line with a broader push from the Biden administration to address health disparities. Regulators have paused a number of models during the review, which found evidence of implicit bias in three payment models.

The internal review found a number of issues and challenges, including a lack of diversity in model tests and complex payment policies and model overlap that can sometimes result in conflicting incentives for participating providers. Many financial benchmarks and risk adjustment methodologies create opportunities for potential gaming and upcoding, and accepting downside risk can be hard for providers without care management tools or protection against beneficiaries with unpredictably high costs.

In addition, select model design features, including voluntary participation, can limit savings due to selection bias, according to the report. The agency plans to trial more mandatory payment models in a bid to address that.

The CMMI said it will also work to embed health equity into every model test, reduce model complexity and provide tools to help providers assume financial risk and redesign benchmarks and risk adjustment where appropriate, among other steps. The agency’s work should streamline its portfolio, resulting in fewer but better designed models, CMMI head Liz Fowler has said.

The CMMI’s goal is to get every fee-for-service Medicare beneficiary and the “vast majority” of Medicaid beneficiaries in an accountable care arrangement by 2030.

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