Gilfillan defends CMMI, promises results at Senate hearing

Interim results from new payment and delivery models tested by Center for Medicare and Medicaid Innovation (CMMI) are forthcoming within a year with recommendations for payment and care changes to follow within two years, Richard Gilfillan, MD, director of CMMI, told the Senate Finance Committee during a March 20 hearing.

The committee put Gilfillan and CMMI in the spotlight after a November 2012 U.S. General Accountability Office (GAO) report found, among other things, CMMI models potentially duplicative with other CMS programs. CMMI was created in November 2010 pursuant to the Patient Protection and Affordable Care Act (ACA) to test new models and delivery programs, including new incentive structures from fee-based to value-based care for more coordination, better outcomes and lower costs.

At the hearing, senators openly questioned the center’s $10 billion, 10-year budget during a time when sequestration is forcing agencies to scale back. Committee members broadly recognized the need for new, innovative ideas to lower cost and improve the quality of the U.S. healthcare system, but quizzed Gilfillan on progress made since the center launched.

Gilfillan said that CMMI currently is analyzing data from two primary care projects: the multi-payer advanced primary care practice and federally qualified health center advanced primary care practice demonstrations. Also, first year results from the Pioneer accountable care organization model will be available this summer, he said.

Overall, the CMMI director expressed confidence that the three dozen models tested by the center will yield programs effective at improving quality outcomes. “Providers and stakeholders are eager to redesign care and participate in models that reward quality and coordination and decrease cost,” he added.

However, “We are all eager to see results, but we need to be realistic. It’ll take time to see improvements,” he said. Typically a model requires 12 months of experience, and three months after that period for claims to fully enter the system for analysis, Gilfillan said, adding that health outcome metrics will come into focus before data on total cost of care.

“You mentioned it takes time. It does take time, but people--at least Congress--are going to be a little impatient,” said finance committee Chairman Max Baucus (D-Mont.), who added that he wanted quantifiable results “not just grand goals and platitudes.”

Gilfillan responded that the need for “complete, accurate and dependable data” is important before formally disclosing results.

He did stress that some models are showing promise in initial stages of implementation. Gilfillan talked about data from the state of Vermont showing a lower-than-expected rate of increase in the total cost of care for a CMMI medical home model there.

Also, in North Carolina, he cited early signs of improvement in the rates of hospitalization, including frequency of Medicare beneficiaries being admitted to the hospital and frequency in which they are visiting emergency rooms.

Another program Gilfillan mentioned in response to a question on models to improve pediatric care included the Strong Start for Mothers and Newborns Initiative that discourages elective deliveries prior to 39 weeks gestation. He said the program is showing signs of reducing the number of babies admitted to neonatal intensive care unit with complications.

On the topic of concerns laid out in the GAO report, he said CMMI developed a centralized database to prevent duplicative payments. Also, the system ensures that no two patients are in the same model.

“There are rules we will use to decide the most likely provider of care to a particular patient. We look at experience of that patient to see who has provided the most care,” he said of determining an appropriate model for a patient.

Much work has occurred at all levels of CMS to ensure no duplication between CMS departments, in particular the Center of Clinical Standards and Quality, Gilfillan said. CMS programs are “synergetic and complementary,” he said. Also, CMMI has worked to guarantee that no programs are launched that overlap with existing efforts.

But Sen. Orrin Hatch (R-Utah) took CMMI to task for another criticism in the GAO report: the purchase of treadmill desks. “We don’t need taxpayer dollars so staff can work at treadmill desks. We need specific goals with specific directions,” he said.

Another issue brought up regarded CMMI’s ability, as permitted through the ACA, to adapt a model on a national scale without congressional approval. Sen. Pat Roberts (R-Kansas) sharply disagreed with CMMI’s ability to bypass Congress.

Gilfillan said no models have reached that point yet, and he’d “follow the usual regulatory pathways” when that happens.

As legislators reiterated again and again whether taxpayers are getting enough for their money, Gilfillan said, “We appreciate the resources we have and there is a great amount of work to be done. We are confident we’ll come back at some future time and be able to demonstrate that to you.”