Center for Medicare and Medicaid Innovation: Who are they and What do they do?

The Center for Medicare and Medicaid Innovation tackles some big -- and oft open-ended – questions: How can we improve care by improving coordination of services? How can we ensure that people leave the hospital with enough supports that they won't be back soon? How do we reduce the number of healthcare-associated infections? How do we prevent babies from being born too soon… get people to take charge of their weight, their diabetes, their lifestyle… get them to quit smoking? How do we support the elderly in the community? What treatments could be delivered in a community setting? What payment models work best? How do we incentive actions -- and hold people accountable?

The Innovation Center was created as part of the Affordable Care Act. Jay Hancock Kaiser, writing for Kaiser Health News, noted that the best known elements of the ACA affected only a small portion of the population and opined that responsibility for fixing for the rest of us fell to the center for Medicare and Medicaid Innovation (https://www.washingtonpost.com/politics/health-laws-center-for-medicare-and-medicaid-has-its-skeptics-about-innovation/2014/08/10/36882e1c-1c22-11e4-ae54-0cfe1f974f8a_story.html). The goal is to reduce the burden of healthcare.

There are occasions when participation in one of the Center’s programs is mandatory. Some organizations are required to participate in episode-based payment models for treating certain types of medical issue (https://innovation.cms.gov/initiatives/epm/). Much of the innovation, though, is tested by very willing, grant-driven participants; they have ideas about what works and want funding to demonstrate it. Some are states. Some are other organizations like health systems. While the main focus of the Center for Medicare and Medicaid intervention is increasing Medicare, Medicaid, and CHIP efficiency, the organizations funded don’t exclusively serve these populations.

The Center manages a large portfolio of projects. Currently models fall into seven broad categories, among them, accountable care, primary care transformation, speeding adoption of best practices, and episode-based payment initiatives. Value-Based Programs seek to curb a problem with U.S. healthcare: that the nation is spending more than its counterparts but seeing worse health outcomes (https://www.ced.org/blog/entry/top-healthcare-stories-for-2016-pay-for-performance).

The Medicaid/CHIP portfolio includes projects run at the state level. Ten states, for example, have grants through the Medicaid Incentives for the Prevention of Chronic Diseases Model to test the use of incentives to reduce chronic diseases among Medicaid beneficiaries. States seek to incentivize healthy behaviors and lifestyle changes. Each targets at least one of the following: tobacco cessation, weight, blood pressure, cholesterol, and/or diabetes avoidance or management. Grantees target different populations and have different incentive structures and different study designs. They may, for example, have varying numbers of groups that they are comparing to see what works best. New York's program is targeting pre-diabetes, diabetes, tobacco use, and blood pressure and comparing results of incentivizing behavior with those of incentivizing health outcomes. Hawaii Patient Reward and Incentives to Support Empowerment Project (HI-PRAISE) is targeting Native Hawaiians who have diabetes or are at risk.

The 2nd Report to Congress, prepared by an independent contractor, found that yes, states were successful in enrolling people in these programs, and people were, by and large, very happy with them. It was too early to tell whether process goals -- for example, enrolling more people in -- would significantly change health outcomes still waiting to see.

Periodically the Center for Innovation issues new calls for proposals with slightly different emphases. In February of 2017, the Innovation Center issued a call for proposals for voluntary episode-based care innovations for pediatric populations (https://innovation.cms.gov/initiatives/pediatric-apm). One goal is to reduce the costs associated with provision of services to pediatric populations who are enrolled in CHIP and Medicaid. The expectation is that this will be accomplished partly through shared accountability, for example, by developing better coordination with early childhood education and community-based programs. The potential gains are not exclusively monetary. Collaborations and shared accountability can also improve health outcomes.

Projects are subject to third party evaluation. Mathematica, a third party consulting company, has provided annual evaluations for a number of models; reports may include analysis of what characterizes more successful programs. It is important to remember that there are different methods used by grantees as well as different methods used by the CMS. In short, there are many approaches to similar problems in play at the same time, and some will inevitably fail. The big successes are candidates for widespread expansion. The failures, too, can offer lessons.

Innovation Center Successes

CMMI delivers an annual report to Congress. The 2017 report was the third. In it, the organization highlighted some of the big successes and summarized other new and ongoing efforts.

One of the big successes is the Medicare Diabetes Prevention Program (MDPP). The grant was awarded to the YMCA. The aim is to use behavioral intervention to prevent pre-diabetes from becoming diabetes. Work carried out between 2012 and 2015 was highly promising; in 2016, it was announced that the program had met criteria for expansion. Beginning in 2015, Medicare enrollees will be offered MDPP services. There will be no cost-sharing.

Also notable is the Pioneer Accountable Care Organization Model. While the original “pioneer” model has ended, there are new generation ACO models being tested.