Slings, Arrows & a Few Good Allies

It must have been the $10 billion budget. That’s the amount allotted, upfront, to fund the Center for Medicare and Medicaid Innovation (CMMI) for 10 years as it tests new payment models designed to curb healthcare costs without sacrificing on healthcare quality. The allocation arrived by way of a section of the Affordable Care Act, and the big dollars—automatically renewable with a fresh $10 billion each subsequent decade—surely helped draw the scrutiny that is now coming from both sides of the political aisle.

Last winter, left-leaning economists, researchers and watchdogs interviewed by the New York Times roundly criticized CMMI for basing its evaluations on 40 or so demonstration projects to the near exclusion of rigorous randomized trials. That approach, they said, will not provide credible solutions to the problems at hand. “Until we do [randomized] studies, we don’t have evidence,” said William Savedoff, a senior fellow at the Center for Global Development.

In the spring, right-leaning counterparts identified CMMI as an example of the sort of “bureaucratic micromanagement” that Congress should “do away with.” Writing in the opinion pages of The Wall Street Journal, they stated: “What’s likely to transpire [at CMMI] isn’t innovation but price controls on medical procedures.” Innovation is needed, they allowed, but it will only happen with “reforms promoting deregulation and more intensive competition.”

For its part, CMMI is standing tall, soldiering on—and hoping for the best in November, when Republicans could regain control of both chambers of Congress. If that happens, CMMI may face an existential threat from forces seeking to defund or repeal Obamacare.

The work does the talking

Understandably, CMMI is feeling skittish about talking to the press. When Clinical Innovation + Technology requested an interview for a spoken update on opportunities and challenges, the center’s press staff initially agreed but then said they were unable to schedule an official for 20 minutes over the phone within a two-week window.

This is unfortunate, as the center is unquestionably making headway in helping to build a more accountable and cost-efficient American healthcare system. Its main focus is on building and testing accountable care organizations, bundled payment models and primary care transformation, but it’s also working to help local and regional stakeholders speed up their own testing of new models—all with an eye on accelerating the adoption of best practices nationally.

“Recent studies indicate that it takes nearly 17 years on average before best practices backed by research are incorporated into widespread clinical practice—and even then the application of the knowledge is very uneven,” CMMI states on its website. “The innovation center is partnering with a broad range of healthcare providers, federal agencies, professional societies and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.”

Future-oriented

Janis Orlowski, MD, senior director of healthcare affairs at the Association of American Medical Colleges, works closely with CMMI and more than 30 hospitals to test bundled payments for care improvement and likes what she’s seeing.

Orlowski describes a recent project to build a hypothetical model of the academic medical center of the future. A team studied how 13 academic medical centers were developing new partnerships and new ways of doing business within specific areas. “We looked not only at academic medical centers that are doing well but also, for example, the University of New Mexico (UNM), where nearly half the patients are either covered by Medicaid or non-paying. We highlighted that delivery system because of that and because they’ve done some novel things with their state legislature.”

UNM leveraged its status as the state’s major tertiary healthcare center and main source of new doctors to get lawmakers to partner more closely with the institution. “That really has led to some novel discussions between New Mexico’s legislators and New Mexico [as a state] about how to get together and design a system that works best for the state,” she says. “UNM is one of the institutions looking at working with us and CMMI on bundled care because they know that they need to change. They know they need to begin to experiment with some of these new payment models.” The hospital system of the future, whether affiliated with a medical school or community-based, she says, may need to take similarly novel approaches in order to survive.

“Our partnership with CMMI has been very strong, and what we see, quite frankly, is a vision of how we may be able to do clinical redesign in the future,” Orlowski adds.

Both sides now

Jon Baron, president of the Coalition for Evidence-Based Policy and one of the voices criticizing CMMI for its lack of rigorous randomized trials, says CMMI sits on a mountain of potential. Such trials need not require heavy investments, he says, as the study designers could repurpose data gleaned during previous clinical studies.

Another Health & Human Services operating division, the Administration for Children and Families, is a potential role model. “They have a long history of doing randomized experiments in many different areas, most notably some excellent studies in welfare to work,” says Baron. “Those studies produced valuable knowledge that helped to form or shape the historic 1996 Welfare Reform Act. The evidence was not only valid but also very influential.”

In like form, CMMI “needs to produce hard evidence that everyone—Democrats, Republicans, everyone—would see as credible as to which approaches work and which don’t,” adds Baron. “That would help to validate their work across the political spectrum.”

Elsewhere in the nation’s capital, U.S. Rep. Phil Roe of Tennessee, co-chair of the Republican Doctors Caucus, isn’t convinced. “I believe we already have centers for innovation in reform—our state governments,” says Roe. “Rather than being removed from the process or forced to swallow a one-size-fits-all, big-government solution, we should empower states to try out innovative healthcare reforms that reduce the cost of care, increase access and improve quality.”

The next election will prove how ominous those words might be to CMMI.