CMS Innovations: Improvement or Same old, Same old?

On Wednesday, September 20, the CMS published an RFI requesting feedback "on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes." Wait. That sounds very familiar, doesn't it? Isn't this what the Affordable Care Act, Meaningful Use, PQRS, MIPS, and a number of other initiatives have tried (or are still trying) to accomplish?

I'm all for innovations that will improve healthcare and reduce cost. And I'm certainly not going to contend that everything is perfect. According to this Investopedia article, the average MRI in the US costs 518% more than an MRI in Spain, but some people are paying up to 1,574% more depending on where they live or the provider they see. You will see similar numbers when comparing a variety of other procedures and treatments with other first-world countries. But, that's okay because the quality of our healthcare must be 518-1574% better, right? Nope. Not even close. By most measures, we are well behind comparable countries in regards to quality. Check out this Peterson-Kaiser Health System Tracker slideshow as a testament to that fact.

So, how is this new direction any different? Should we be hopeful? Let's explore it a bit…

The RFI is officially found here, where you can jump to the full 9-page RFI in PDF form.

The background and guiding principles seem solid. The goals seem noble (if not all too familiar). Two things that stick out as being very promising are transparency and small-scale testing…though I'm skeptical of pulling off the latter in a way that is representative of the whole AND scalable.

A short summary of the potential models that will be used:

1. Expanded Opportunities for Participation in Advanced APMs

Long story short: CMS is seeking comment on how to reduce the overhead for providers to qualify, how to improve CMS responsiveness, and how to improve the capture of appropriate data.

2. Consumer-Directed Care & Market-Based Innovation Models

Long story short: CMS is seeking comment on how to increase transparency of cost and quality to consumers and find ways to incentivize choosing the highest-quality, lowest-cost providers.

3. Physician Specialty Models

Long story short: CMS is seeking comment on how to increase the ability for specialty physicians to participate in APM's in an effort to improve quality and decrease cost of specialty care (such as Cancer).

4. Prescription Drug Models

Long story short: CMS is seeking comment on how to increase drug pricing competition to decrease costs, while also ensuring that outcomes and access to necessary drugs improve.

5. Medicare Advantage (MA) Innovation Models

Long story short: CMS is seeking comment on how to improve MA plans to better compete for beneficiaries based on quality, cost, and transparency.

6. State-Based and Local Innovation, including Medicaid-focused Models

Long story short: CMS is seeking comment on how to drive better outcomes for people based on local needs by partnering with states and local healthcare providers to develop state-based plans and local innovation initiatives.

7. Mental and Behavioral Health Models

Long story short: CMS is seeking comment on how to improve mental/behavioral healthcare, including focus areas such as opioids, substance use disorder, dementia, and improving mental healthcare provider participation in Medicare, Medicaid, and CHIP.

8. Program Integrity

Long story short: CMS is seeking comment on ways to reduce fraud, waste, and abuse and improve program integrity.

From a high level, the models outlined here and the methods by which they are proposing accomplishing the goals seem very exciting to me. Obviously, ideas are cheap, and it is often at the time of execution that government programs stumble. What do you think? Could improvements be coming that will improve care, decrease cost, and allow healthcare organizations to remain profitable enough to keep innovating?

I would personally be interested in your thoughts on this and how you feel this might impact the industry. But even more importantly, if you're a stakeholder I urge you to review the entire RFI here and post your public comments via the official online submission form.

About the Author: Rob Fea

Rob Fea leads the Professional Services and Data Capture teams at Extract. Rob plays a large role in software implementation, customer success, process improvement, and product design. Rob’s primary focus is on the healthcare suite of products. Prior to Extract, Rob spent 12 years partnering with IT teams and clinicians at major hospitals and clinics worldwide during his tenure on the technical services team at Epic. Rob supported Epic's Phoenix product, playing a major role in project kickoffs, installation, data conversions, ongoing support, and optimization. Rob watched the Phoenix customer base expand from zero to 55. This experience gave Rob expansive insight into the healthcare world, especially the solid organ transplant industry. Rob has spent countless hours on the floor in transplant departments observing multidisciplinary visits, committee review meetings, data entry, data trending, reporting, medication dosing, and more.