Innovative Initiatives in Healthcare Transformation

CMS Innovation Center New Direction Request for Information Steven Farmer, MD, PhD Senior Advisor and Medical Officer CMS Innovation Center Centers for Medicare & Medicaid Services

Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

3 5/4/2017 CENTERS FOR MEDICARE & MEDICAID SERVICES

Size and Scope of CMS Responsibilities CMS is the largest purchaser of health care in the world Combined, Medicare and Medicaid pay approximately one-third of national health expenditures (approx $800B) The Medicare program alone pays out over $1.5 B in benefit payments per day CMS programs currently provide health care coverage to 1 in every 3 Americans

Department-Wide Strategy a health care system that results in better accessibility, quality, affordability, empowerment, and innovation Less bureaucratic and complex Reduces burden for clinicians, providers and beneficiaries

Putting People First Empowered Providers Beneficiaries have the information they need to make informed choices, and are in charge of their healthcare State Flexibility States can design programs to meet unique challenges Quality, accessibility, affordability, and data drive innovation Technology prevents fraud, waste, and abuse Innovative Approaches Customer Experience Internal and external stakeholders have an improved experience Operational Excellence Continuous improvement drives sustained change

7 5/4/2017 CMS INNOVATION CENTER

The CMS Innovation Center was created to develop, test, and implement new payment and delivery models The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles Three scenarios for success*: 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) *If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking

Transformation of Health Care at the Front Line At least six components: Quality measurement 1. Aligned payment incentives 2. Comparative effectiveness and evidence available 3. Health information technology 4. Quality improvement collaboratives and learning networks 5. Training of clinicians and multi-disciplinary teams 6. Source: P.H. Conway and Clancy C. Transformation of Health Care at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5 9

The Innovation Center portfolio aligns with delivery system reform focus areas Focus Areas CMS Innovation Center Portfolio* Test and expand alternative payment models Accountable Care ACO Investment Model Pioneer ACO Model Medicare Shared Savings Program (housed in Center for Medicare) Comprehensive ERSD Care Initiative Next Generation ACO Bundled payment models Bundled Payment for Care Improvement Models 1-4 Oncology Care Model Comprehensive Care for Joint Replacement Initiatives Focused on the Medicaid Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program Dual Eligible (Medicare-Medicaid Enrollees) Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents Integrated ACO Medicare Advantage (Part C) and Part D Medicare Advantage Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Pay Providers Primary Care Transformation Comprehensive Primary Care Initiative (CPC) & CPC+ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Home Health Value Based Purchasing Medicare Care Choices Frontier Community Health Integration Project Medicare Diabetes Prevention Program Support providers and states to improve the delivery of care State Innovation Models Initiative SIM Round 1 & SIM Round 2 Maryland All-Payer Model Pennsylvania Rural Health Model Vermont All-Payer ACO Model Learning and Diffusion Partnership for Patients Transforming Clinical Practice Deliver Care Health Care Innovation Awards Accountable Health Communities Million Hearts Cardiovascular Risk Reduction Model Increase information available for effective informed decision-making by consumers and providers Distribute Information Information to providers in CMMI models Shared decision-making * Many Innovation Center programs test innovations across multiple focus areas

CMS has engaged the health care delivery system and invested in innovation across the country Models run at the state level Sites where innovation models are being tested Source: CMS Innovation Center website, February 2017

The CMS Innovation Center is undergoing a re-assessment Reviewing existing models against new direction: Adjustments to policy Introduction of new features Soliciting public feedback on new model concepts: Exploring and refining concepts Assessing interest 12

RFI Solicits Ideas on How to: Promote patient centered care Test market driven reforms Empower beneficiaries as consumers Provide price transparency Increase choices and competition to drive quality Reduce costs Improve outcomes 13

Guiding Principles Choice and competition in the market: Competition based on quality, outcomes, and cost Provider choice and incentives: Voluntary models Reduce burdensome requirements and unnecessary regulations Patient centered care: Empower beneficiaries, families, and caregivers to take ownership of care 14

Guiding Principles Benefit design and price transparency Transparent model design and evaluation Small scale testing: Smaller, more nimble models Focus on payment interventions rather than specific tests or treatments 15

16 5/4/2017 FOCUS AREAS

Advanced Alternative Payment Models Eligible clinicians who are Qualifying APM Participants (QPs) between 2019 and 2024: Lump-sum incentive payment Higher update of Physician Fee Schedule (PFS) after 2026 Not subject to Merit-based Incentive Payment System (MIPS) reporting, payment adjustments The Innovation Center is exploring how to: Increase number of QPs Strategies to incent eligible clinicians Capture appropriate data to drive model design 17

Physician Specialty Models Improve availability of specialty models: Independent physician practices Chronic management models Variations of the Oncology Care Model concept Physician-Focused Payment Model Technical Advisory Committee (PTAC): Growing number of submissions Secretary may make recommendations to the Innovation Center 18

Consumer-Directed Care & Market Based Innovation Models Consumer-directed models could empower beneficiaries to chose providers in market-driven healthcare system: Encourage price and quality transparency Public reporting Promote consumerism and transparency: Direct contracting with healthcare providers Providers propose prices for bundled services Bidding for bundled services Preferred provider networks 19

Medicare Advantage (MA) Innovation Provide MA plans with greater flexibility to innovate Medicaid Advantage Value-Based Insurance Design (VBID): Incentives to chose high-value services Competitive bidding for beneficiaries: Quality and cost 20

State-Based and Local Innovation Partner with states to drive better outcomes: State Innovation Models Innovation Accelerator Program Strong Start Medicaid Incentives for Prevention of Chronic Disease State models are customized to local needs: Offer more local flexibility Multi-payer reforms 21

Mental and Behavioral Health Exploring models focused on: Opioids / substance use disorder Dementia Improving mental healthcare provider participation in Medicare, Medicaid, and CHIP 22

Prescription Drug Models Prescription drug models under-represented: Part B, D, and Medicaid Better align incentives, engage beneficiaries Value based purchasing programs Increase pricing competition 23

Program Integrity Desire to balance program integrity with burden on patients and providers Seeks input on: Reducing fraud and abuse Improving program integrity 24

25 5/4/2017 QUESTIONS

Questions Comments on guiding principles Model designs (structure, approach) Options beyond FFS and MA for improving value How can CMS better engage beneficiaries in model development Payment waivers that CMS should consider Other comments 26

Feedback RFI solicits public feedback, not a commitment to pursue specific idea or approach Draw responses from objective, empirical and actionable evidence Your feedback will be carefully reviewed and considered 27

New Direction - CMS Innovation Center Request for Information (RFI) The RFI seeks broad input related to a new direction for the CMS Innovation Center that will promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, and improve outcomes. Guiding Principles Choice and competition in the marketplace The administration plans to launch models in several focus areas: Provider choice and incentives Expanded Opportunities for Participation in Advanced APMs Consumer-Directed Care & Market-Based Innovation Models Physician Specialty Models Physician-Focused Payment Model Technical Advisory Committee (PTAC) Recommended Models Prescription Drug Models Medicare Advantage (MA) Innovation Models State-Based and Local Innovation, including Medicaid-focused Models Mental and Behavioral Health Models Program Integrity Patient-centered care Benefit design and price transparency Transparent model design and evaluation Small scale testing Submit feedback & ideas @ innovation.cms.gov/initiatives/direction/ through November 20, 2017

Thank you Steven.Farmer@cms.hhs.gov 29