CMMI director hints at shift away from payment models for every episode of care, specialties

The Biden administration wants to move away from creating value-based care payment models for every type of disease, episode of care or specialty groups to streamline its projects, a top official said.

Center for Medicare and Medicaid Innovation (CMMI) Director Liz Fowler said during a briefing Tuesday hosted by the Alliance for Health Policy that more mandatory models are needed, including those that focus on the total cost of care.

“In my mind, I think we should look down the mandatory model line … but we need to move away from having a model for every episode and specialty group,” Fowler said.

CMMI has undertaken a major review of the center’s existing payment models to determine what works and what doesn’t. A key finding was that voluntary models have problems with risk selection.

“People that stay in our models till the end are more likely to succeed or … have resources to participate,” she said. “We are not capturing a certain segment of the provider community.”

RELATED: CMS: Don't expect a lot of fully risk-based payment models going forward

Fowler was more in favor of promoting models that address the total cost of care, like Maryland’s state model that sets a per capita limit on total Medicare costs in the state.

“We are looking at incorporating more safety net providers in that system and encouraging more closer collaboration with Medicaid,” she said, referring to Maryland’s model.

But that doesn’t mean the center is going to shy away from specific models on a certain specialty. The center is currently taking comments on a radiation oncology mandatory model and the comprehensive joint care model.

However, Fowler said there will be a major emphasis on ensuring any new episode of care models would be harmonized and streamlined for accountable care organizations.

“I don’t know that we want to create a diabetes model that undermines the movement of ACOs or takes away the ability of ACOs to recruit physicians,” she said. “We need to make sure that the models are harmonized and working together.”

Fowler reiterated that advancing health equity will continue to be a major factor in developing new models. Part of that is increasing the participation of safety net and rural providers to help ensure value reaches underserved areas.

Another goal is to improve coordination with Medicaid and the Children’s Health Insurance Program to make sure “are we asking the right questions [and] are we going where innovation is needed in those programs,” she said.