CMMI’s Adam Boehler wants to ‘blow up’ fee for service

At ONC's annual conference, Adam Boehler said HHS' prime goal is to "get rid of fee for service." (ONC)

If there was any doubt about the Trump administration’s desire to push healthcare towards a value-based system, Center for Medicare & Medicaid Innovation (CMMI) Director Adam Boehler wiped it away on Thursday morning.

“I'll tell you a lot of what I do in my role running CMMI as senior adviser to Secretary Azar is to blow up fee for service,” he said during a fireside chat at the Office of the National Coordinator’s annual conference. “That's one of our prime goals—is to get rid of fee for service.”

It’s not the first time that Boehler, who was appointed to the position in April, has taken such a decisive stance. Prior to his appointment, Boehler was the CEO of Landmark Health, a medical group that focuses on integrating technology to care for chronically ill patients at home and operated largely on value. During his time at the Department of Health and Human Services (HHS) he has expressed support for alternative payment models (APMs), noting that CMMI can play a role in finding providers that are ready to take on more risk. The administration has proposed significant changes to the Medicare Shared Savings Program to facilitate that shift among ACOs.

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But killing off fee-for-service entirely will be easier said than done given the industry’s reliance on the existing infrastructure. Boehler’s counterpart at Thursday’s fireside chat, Sen. Lamar Alexander, R-Tenn., cautioned that the shift to value can’t happen all at once and advocated for giving states the leeway to experiment so the rest of the country can determine what approaches work best.

A recent report showed 34% of healthcare payments were tied to an alternative payment model in 2017. Medicare fee-for-service has showed notable gains with just 10.5% of payments in traditional legacy arrangements not linked to quality. More than half have some level of pay-for-performance.

But just 38.5% of Medicare payments had more robust incentives like shared savings, bundled payments or population-based payments and integrated delivery systems.

The Obama administration set a goal to tie 50% of Medicare payments to value-based models, but there’s been no indication the current administration will stick to that threshold. CMMI itself has underwent a significant overhaul last year, and ended several Obama-era mandatory bundled payment models.  

“I don't know there's any question that when you have a payment system based on volume, you get exactly that—volume and high prices,” Boehler said. “So we're going to look really at saying, how do you have physicians spend time with their patients and do what they do best and not worry about their revenue cycle but worry about their patients and how you drive outcomes.”

But Boehler has the support from some private sector insurers, including Patrick Conway, M.D, the former CMMI director and current president and CEO of Blue Cross Blue Shield of North Carolina.

“I want fee-for-service, volume-based care to die,” Conway said during a summit last month , “and I want to kill it as fast as possible.” 

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