Donald Berwick, MD, former head of the Centers for Medicare and Medicaid Services and Richard Gilfillan, MD, former head of the Center for Medicare and Medicaid Innovation (CMMI) write in JAMA Network about the value of CMMI, a creation of the Affordable Care Act that has just reached its tenth year of operation.
Before CMMI, there was no governmental agency charged with looking scientifically into how best to reshape our nation’s health care financing and delivery systems. Specifically, CMMI is supposed to test new ways of delivering and paying for care that bring down spending while maintaining or improving quality or improve quality while either not increasing spending or reducing it.
CMMI has significant resources to work with. It has $20 billion to test new models of delivering and paying for care over 20 years, or $1 billion a year. The Secretary of Health and Human Services (HHS) has authority to bring CMMI models to national scale that fit within the parameters of its work, without requiring legislation.
Between 2010 and 2020, CMMI tested 54 models. Some of these models focused on better care for individuals and better population health, while spending less. Some tested new models of delivering primary care, including medical homes and accountable care organizations. And, some models tested new ways of paying for care, through bundled payments for a group of services over a period of time, instead of through a payment for each service delivered.
One independent review found that fewer than ten percent of the models tested led to significant reductions in spending. CMMI reports on its website that nearly 10 percent of models tested improved quality and/or reduced costs.
Beyond that, the tests showed where the savings could be found and where not, as well as where and how the system could be gamed. As of now, CMS has certified four models to be scaled nationally, including a national diabetes prevention program.
Berwick and Gilfillan recommend that CMMI model tests should be aligned with an HHS and CMS strategic plan for improving health and health care value and promoting equity. They also recommend that, over time, the ACO model should apply to all clinicians and hospitals, which would be paid a capitated rate for the total cost of care. They recommend CMMI test models that focus on social determinants of health, in partnership with other executive branch departments, such as the Department of Transportation and the Department of Housing and Urban Development. They recommend that CMMI test new models of care delivery. And, they recommend increased public-private partnerships to promote better health care and the public health. The entire evaluation process should be public.
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