CMS Innovation Center Expects to Play Major Role in Forging New Payment, Care Delivery Models

One of the overriding goals of the Patient Protection and Affordable Care Act (906-page PDF; About PDFs) is to shift the focus of the U.S. health care system from an acute care model to a wellness and prevention paradigm that rewards seamless and coordinated care. That goal is exemplified by the creation of the Center for Medicare and Medicaid Innovation, or CMMI.

"The purpose of the innovation center is to identify, validate and diffuse new care models and to deliver better health, better care and reduce costs through continuous improvement," said family physician Richard Gilfillan, M.D., M.B.A., acting director of the CMMI, in an interview with AAFP News Now. "Our goal is to go out there and identify models that can deliver those outcomes and support them, to help them get up and going, and to evaluate them to see whether they can fulfill that promise."

In many ways, the CMMI represents an investment in primary care and in the patient-centered medical home, or PCMH, model of care. Although the law gives CMS, which oversees the CMMI, significant flexibility in selecting innovations to be tested, it specifically prioritizes testing of new models of primary care delivery. For example, it suggests testing the PCMH model for high-need individuals, women's health care, and comprehensive or salary-based payment of clinicians, notes a report produced by the Commonwealth Fund. The Affordable Care Act also recommends establishing community-based health teams to support medical homes within small physician practices.

"We have a very explicit charge here, which is to reduce program expenditures over time," said Gilfillan during a speech at a December Health Affairs conference. "We believe most of our efforts should be directed to and will be directed to projects that deliver better quality at reduced costs at the same time. In fact, those two go hand-in-hand. We will look for projects that deliver that outcome."

Gilfillan urged physicians, payers and other organizations to propose projects for the CMMI that start with the patient. "Think about the needs those patients have," he said. "Think about interventions and programs and models of care that change the experience of those patients and make a difference."

According to Gilfillan, the CMMI will serve as a conduit for a more rapid diffusion of best practices and information about how to best operate alternative care systems. The center represents a transition strategy, not only for CMS, but for physicians and other health care professionals who interact with the agency, he said. "This is about transforming (CMS) from a claims payer (that) supports fragmented care to a value-added partner supporting seamless coordinated care."

He noted that the CMMI will operate based on three precepts:

"Organizing the (CMMI) around these three levels of care is the most effective way because each one of those levels takes us out of Washington and into the communities and delivery systems of America," said Gilfillan. "That is where the new health system will be created."

And HHS will be able to spread best practices more rapidly because provisions in the Affordable Care Act give the agency the authority, without seeking legislative approval, to spread successful innovations sponsored by the CMMI to all Medicare and Medicaid programs, as well as to the Children's Health Insurance Program, or CHIP. If the tested innovations demonstrate improvements in quality without increased spending or reductions in spending without compromising quality, or both, the model can be spread voluntarily to Medicare, Medicaid and CHIP, according to the Commonwealth Fund report.

Gilfillan refers to this particular provision as the most interesting part of the entire health care reform act. It creates the possibility for "real innovation" and allows CMS to find a health care system that improves the experience of care, improves the health of populations and reduces the per capita cost of health care.

"If you think about a system where you want doctors and hospitals and other providers to be constantly improving how they are operating, how they are connected, how they relate to each other, (then) we need to be able to change the way we pay and support them," said Gilfillan.

One way the CMMI could do this is to spur widespread adoption of the PCMH.

"Thus far, studies indicate that medical homes would meet the test of improving quality without increasing spending or actually reducing spending and not compromising quality," said Melinda Abrams, M.S., VP at The Commonwealth Fund and an author of its report on the Affordable Care Act and primary care.

The report points out that an independent analysis (149-page PDF; About PDFs) from the Lewin Group estimates that widespread adoption of the PCMH by Medicare and Medicaid could reduce national health spending, relative to currently projected levels, by an estimated $175 billion through 2020 if it is tied to positive incentives for patients to participate and is embedded in supportive care systems.

"We certainly are aware of these patient-centered medical homes as a promising way to meet those objectives in a new care system," said Gilfillan.