Center for Medicare and Medicaid Innovation: What Patients Need to Know

Let’s face it: health care is confusing.

For patients, it’s a challenge just getting the right person on the phone. Then comes the endless insurance paperwork, frustrating delay tactics and barriers to access. At the end of the fight for access, patients have precious little energy left to focus on our own health – let alone the bigger public policy debate about health care reform.

Here at Patients Rising, one of our goals is to help guide patients through our inexcusably complex health care system. If we’re ever going to gain the upper hand in the fight for health care reform, patients need to engage with the obscure health care agencies that decide questions of access.

Here’s one federal health care agency that every patient should know: Center for Medicare & Medicaid Innovation.

What is the Center for Medicare and Medicaid Innovation?

The Center for Medicare and Medicaid Innovation, a division of the Centers for Medicare and Medicaid Services within the Department of Health and Human, is developing new health care financing models that will determine every patient’s ability to access health care.

You’ll often see the Center for Medicare & Medicaid Innovation abbreviated as CMMI, or the Innovation Center.

Created by the Affordable Care Act, CMMI has broad authority to conduct its own experiments with ways to cut health care costs. When CMMI implements an “alternative payment model” in a segment of health care, it can have major consequences for patients and dramatically change which treatments are available, when patients can access them and who is ultimately in charge of medical decisions.

Why It Matters to Patients: Center for Medicare and Medicaid Innovation Will Determine Your Access to Care

Although it’s an obscure government agency, the Center for Medicare and Medicaid Innovation can have profound consequences for patients’ ability to access the right treatment. That’s because it’s one of the leading forces in imposing “value” assessments in health care. Value frameworks and cost-cutting policies often lose sight of the patient’s best interest.

“The most appropriate treatment for a patient should be determined by the patient and their doctor. Period,” explains Terry Wilcox, our co-founder and executive director. “If a value payment model of any kind does not put that relationship and decision making process at the top of the pyramid, then it is a failure.”

The Problem: Center for Medicare and Medicaid Innovation Doesn’t Follow Standard Rule-Making Process

New health care proposals often start at the Center for Medicare & Medicaid Innovation — that’s troubling considering most patients have never heard of it.

Even more concerning, the cost-cutting agency isn’t required to follow the standard rule-making process for government regulatory agencies.

“CMMI has greater independence in developing and implementing demonstration projects than has been typical for regulatory actions undertaken by executive branch agencies,” explained Dr. Joseph R. Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute, in his testimony before the House of Representatives Committee on Budget. “In contrast (to every other agency), CMMI has the authority to develop policy for the Medicare program de novo, and may test any new policy approach without specific direction from Congress.”

“This allows CMMI to roll out new proposals quickly without a formal opportunity for public comment or agency responses to such comments.”

CMMI in Action: “Dangerous Experiment with Medicare Part B”

In 2016, CMMI’s power was on full display — with its experiment with Medicare Part B.

It’s of vital importance to every cancer patient in the country. As every oncologist knows, Medicare Part B covers medical services and supplies considered medically necessary to treat a disease or condition.

CMMI’s proposal would have undercut cancer patients’ ability to access the treatments recommended by their doctors. Patients Rising joined more than 300 health care organizations, representing patients, doctors, and oncologists, in objecting to the changes. There was even bipartisan agreement from liberal and conservative members of Congress that CMMI’s experiment could threaten patients’ access to life-saving treatments.

“The Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services has proposed a dangerous experiment with Part B drug payments,” warned Rep. Buddy Carter, a conservative Republican who represents Georgia’s 1st Congressional district. “This will put patients at tremendous risk, potentially forcing them to abandon the best treatments for other treatments that have proven less successful. Ultimately, CMS will create an end run around the doctor-patient relationship to dictate treatments. This is unacceptable.”

After public outrage and congressional input, the agency backed away from the proposal. “We are pleased the Center for Medicare and Medicaid Innovation has decided not to move forward,” House Minority Leader Nancy Pelosi, D-CA, said in a statement.

Take Action: How Patients Can Improve Medicare’s Cost-Cutting Agency

How do we prevent similar dangerous experiments in the future? Bring the patient voice to CMMI.

Patients are taking action to ensure that the patient voice is heard at the Center for Medicare and Medicaid Innovation. Patients Rising has joined “Healthcare Leaders for Accountable Innovation in Medicare and Medicaid,” a coalition of more than three dozen health care organizations representing patients, hospitals, physicians, and healthcare leaders.

The coalition, which includes the American Autoimmune Related Diseases Association, American College of Rheumatology, Community Oncology Alliance, Lupus and Allied Diseases Association, Inc., Mended Hearts, Inc., National Alliance on Mental Illness, and Veterans of America, has proposed a set of reform principles to bring greater transparency, improved data-sharing, and a stronger patient voice to CMMI.

The principles call for CMMI to:

  • Foster strong scientifically valid testing prior to expansion. Initial CMMI experiments of new payment and delivery models should have comprehensive, methodologically sound, transparent evaluation plans and occur via appropriately scaled, time-limited tests in order to protect beneficiaries and participants from unintended or adverse consequences. Participation in model tests must be voluntary and should be structured in such a way to ensure valid results.
  • Respect Congress’s role in making health policy changes. The legislative branch has a responsibility to oversee CMMI and must approve model expansions and related changes to Medicare and Medicaid. CMMI’s important work in testing new models that improve quality or reduce costs without harming beneficiary access or healthcare outcomes should inform congressional decisions on national health policy.
  • Consistently provide transparency and meaningful stakeholder engagement. CMMI’s process for developing, testing, and expanding models must be more open, transparent, and predictable to provide meaningful opportunities for stakeholder input, ensure safeguards for patients and providers, and improve accountability. This includes: developing new models in close consultation with affected stakeholders, maintaining complete transparency in decision-making and program procedures, and fully evaluating data and seeking patient and stakeholder input prior to model expansions.
  • Improve sharing of data from CMMI testing. Data from CMMI model tests should be made public on an ongoing basis to facilitate assessments of their impact on healthcare quality and spending, and to inform parallel efforts in the private sector.
  • Strengthen beneficiary safeguards. Beneficiaries must not be compelled to participate in a demonstration project and must be adequately educated about the project as well as protected by safeguards to ensure continued access and care quality.
  • Collaborate with the private sector. For CMMI to have an optimal impact on improving healthcare quality and cost-efficiency, it must work collaboratively with the private sector and harness market competition and innovation. In selecting demonstration projects, priority should be given to partnerships involving providers, payers, and other private sector entities throughout the healthcare continuum. CMMI models should support private sector organization efforts to advance healthcare value, rather than impeding such efforts by picking winners and losers in the market.

“These principles will go a long way toward focusing the important work of CMMI on appropriately-scaled projects that align Medicare payment structures with our patients’ healthcare needs,” says Dr. Angus Worthing, a practicing rheumatologist and chair of the American College of Rheumatology’s government affairs committee.

Ultimately, we need patients involved in the Center for Medicare and Medicaid Innovation’s decision-making process.

Find out more about Healthcare Leaders for Accountable Innovation in Medicare.

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