In the spirit of the New Year, I reflected on an institution with one of the more captivating bureaucratic names: the CMS Innovation Center.
Despite its questionable success in the nearly 13 years since its inception, I'm encouraged by the CMS Innovation Center's Strategy Refresh and see unique value in government-derived innovation -- value that the private sector cannot, or will not, afford the general public. While some have called for an end to the program, I say we stick with it.
Origin and Purpose
Known by its official name, the Center for Medicare & Medicaid Innovation (CMMI), the CMS Innovation Center was via the passage of the Patient Protection and Affordable Care Act (ACA) in 2010. According to , one of the three goals of the ACA is to "support innovative medical care delivery methods designed to lower the costs of healthcare generally." With this charge in mind, CMMI was created as an entity within HHS with liberty to devise, trial, and study innovative (value-based) care pilot models within the constructs of the public insurance programs: Medicare, Medicaid, CHIP, and the marketplaces. The ACA afforded the Secretary of HHS latitude to expand successful CMMI pilot models within public programs.
Performance to Date
The performance of CMMI since its inception has been underwhelming. Over have been trialed by CMMI, with only six resulting in savings and just two of those also resulting in improved quality, and four having been expanded as permanent parts of Medicare.
CMMI has received since its inception: $5 billion upfront in 2010 followed by two separate 10-year, $10 billion appropriations. The Congressional Budget Office (CBO) in September 2016 that $45 billion would be saved between 2017 and 2026 -- savings predicated upon the expansion of theoretical CMMI models that had not yet been devised. from 2022 paint a much murkier picture over the same 2017-2026 interval with anticipated net losses of $9.4 billion as a result of CMMI models.
In short, CMMI has produced an overall low success rate. In its 32-page , CMMI makes no mention of dollars saved. Rather, they tout the "important lessons" and "operational insights" learned from the over 50 models tested.
Current Role of CMMI
It is estimated that CMMI models have affected 41.5 million people through its models since 2020 alone, just over 12% of the population. CMMI recognized its shortcomings and released their Strategy Refresh in late 2021, a paradigm shift that involves 1) expanding the number of beneficiaries involved in accountable care, 2) studying and advancing health equity, 3) including patient stakeholders, 4) improving access and affordability, and 5) promoting multi-payer alignment.
If acted upon, this is a significant change in organizational strategy. Where CMMI was previously throwing models at the wall to see what stuck (in regard to two metrics: quality and cost), they will now have to act more efficiently to monitor their progress toward the more difficult-to-achieve benchmarks of equity, stakeholder inclusion, and multi-payer alignment.
Reflections and Resolutions
Many have criticized CMMI for its poor performance. And based on the results, rightly so.
Defenders of CMMI argue that it has facilitated a more widespread public and private transition to value-based care. Some say that the poor performance is justified as CMMI is hamstrung by the narrow pilot trial regulations of less than 5-year duration only within a subsection of public programs. Others may be buoyed by the CMMI revamp, convinced that expanding programs to more beneficiaries and aligning payers within accountable care structures will be the solution.
Overall, I am skeptical how much cost CMMI will actually save. With only four of over 50 models implemented, I wonder how much potential there truly is to "innovate" within the confines of the current healthcare environment. The leaders of CMS, CMMI, Medicare, and Medicaid/CHIP that our healthcare system is "fragmented and siloed." Is it possible that it is too fragmented at this point to benefit from "novel" accountable care models? Have we maxed-out the ability to innovate within the current system? Does each CMMI pilot model simply provide a new set of quality metrics to be gamed, particularly by those (networks, providers, and often by extension, patients) with more resources? Unless our healthcare system undergoes radical change (unlikely), this may well be the case.
Despite its shortcomings, I certainly do not think CMMI should be scrapped as its harshest critics suggest. At least not anytime soon.
The Strategy Refresh is compelling. Not only does it aim to reduce costs through the expansion of models to more beneficiaries and the promotion of multi-payer alignment, but it also presents a revitalized mission focusing on health equity, access, and stakeholder participation.
The classic existential argument against CMMI is that the private sector is better poised to respond to market incentives and can more efficiently implement and refine value-based care models. However, with the Strategy Refresh, CMMI now has the added objective of pursuing health equity and access. I believe that the pursuit of equity requires at least some degree of government-derived innovation and intervention if there is to be any real chance of success.
Maybe the Strategy Refresh will be the panacea. Or maybe CMMI continues to underperform as it pertains to metrics of cost and equity. The alternative? Entrusting the private sector with the duty of promoting equity on its own -- or not aiming to promote equity at all. But it's the likely consequences that would result from having no public institution responsible for devising more equitable and efficient care models that 100% sell me on the continued need for CMMI.
My resolution is to continue to give CMMI a shot.
is a medical student at the Icahn School of Medicine and an advisory board member of 51˶'s "The Lab."