MSSP and Demonstration Projects

Overview

The Center for Medicare and Medicaid Innovation (CMMI) was established in 2010 to develop and test new health care payment and service delivery models in hopes of reducing health care costs and improving quality nationwide.  To that end, CMMI has implemented a number of value-based demonstration projects involving alternative payment models (APMs).  For some demonstration projects, provider participation is wholly voluntary.  For others, participation is mandatory among those providers selected by CMMI in designated metropolitan statistical areas (MSAs).  One such mandatory projects -- the Comprehensive Care for Joint Replacement (CJR) model -- tests bundled payments and quality measurements for episodes of care originating in hospitals and associated with hip and knee replacements (the most common inpatient surgeries for Medicare beneficiaries).  Since CJR went live in April 2016, it has been implemented by approximately 800 hospitals in 67 MSAs across the country.

Public and private reaction to mandatory demonstration projects has been mixed and agency output not always easy to interpret with the Centers for Medicare and Medicaid Services (CMS), in close succession, announcing plans to discontinue a pending mandatory Medicare Part B Drug demonstration project and releasing final rules authorizing four new mandatory demonstration projects: the Acute Myocardial Infarction (AMI) Model, Coronary Artery Bypass Graft (CABG) Model, Surgical Hip and Femur Fracture Treatment (SHFFT) Model, and Cardiac Rehabilitation (CR) Incentive Payment Model. These are currently slated to run from July 1, 2017 to December 31, 2021.

President Trump’s nominee for Secretary of Health and Human Services (HHS), Congressman Tom Price, has vocally opposed mandatory programs in the past, casting doubt on their role in the administration’s policy agenda.  In September 2016, Price and 178 other members of Congress signed a letter registering opposition to CMMI’s mandatory programs on the grounds that CMMI had exceeded legislative authorization, failed to sufficiently engage stakeholders, and upset the balance of power between the legislative and executive branches. A former physician, Price has also voiced concern over aspects of value-based health care such as the burden on physicians of quality reporting requirements. 

Under Price’s leadership of HHS, the trend toward value-based health care could slow and federal support for CMMI’s mandatory APMs and care delivery innovations could dwindle, if not disappear.  Indeed, on January 12, 2017, the Senate passed a budget resolution laying the foundation for legislative repeal of certain elements of the Affordable Care Act (ACA).  Although there is no known replacement for the ACA, both Congressman Paul Ryan’s “Better Way” roadmap (page 32) and Price’s previously-proposed replacement, the “Empowering Patients First Act,” call for CMMI’s repeal.  As a result, the outlook for mandatory participation projects and even CMMI’s future is, at best, uncertain but the political tide could open opportunities for providers seeking to participate in voluntary programs more broadly administered by CMS.