CMMI Chief Fowler: Value-Based Care at a Crossroads

The Center for Medicare & Medicaid Innovation (CMMI) remains committed to moving the health care system towards value-based care in the early years of the Biden Administration, though the center’s leadership is doing some soul-searching on how best to pursue its mission, according to CMMI’s new director Liz Fowler. 

Fowler made her first public remarks since taking the helm at CMMI at the National Association of Accountable Care Organization’s virtual conference. CMMI has developed a number of payment model demonstrations that give hospices access to value-based programs, but with the change of administration the future of some of those initiatives is uncertain.  

“We are 100% committed to expanding access to health care, and we are equally committed to continuing to move our system towards value,” Fowler said at the conference. “But I’ll be honest, I think we’re at a crossroads right now. Collectively, all of us need to draw on what we’ve learned from the last 10 years and chart a path for the future together.”


Federal law allows the Center for Medicare and Medicaid Innovation (CMMI) to test innovative payment and service delivery models that have the potential to reduce federal expenditures, while maintaining or improving the quality of care for beneficiaries.

In recent months the CMMI has slowed down some Trump-era payment demonstrations, indicating that the programs are “under review.” These include the Primary Care First Serious Illness Population model and the geographic direct contracting programs. The U.S. Centers for Medicare & Medicaid Services (CMS) also announced that it would not be accepting applications for the second year of the high-needs, global or professional direct contracting models. The first year of the direct contracting program launched April 1.

The Seriously Ill Population payment option, a component of the larger Primary Care First initiative, is designed to serve patients with complex, chronic needs who have received fragmented care.


The direct contracting options include three voluntary payment models that are designed to help CMS and health care providers reduce the cost of care and improve quality within Medicare fee-for-service programs. The models adapt and integrate concepts from other programs such as Accountable Care Organizations, the Medicare Shared Savings Program, and Medicare Advantage, as well as strategies used in the private sector.

“We want our alternative care models to position participants for success, and sometimes that means speeding up when there’s an opportunity,” Fowler said. “Sometimes it means taking a beat to ensure that a forthcoming model can realistically deliver on what’s intended — that it’s the strongest option based on our evidence and data.”

Fowler gave no specifics on the future of those programs, but affirmed the center’s stance on expanding value-based care. She is working within others in CMMI to develop a prioritized work plan that will chart a path forward for the center. Top priorities will include improving equity in the health care system, expanding value-based care programs and becoming more engaged with the Medicaid program. Fowler also cited multipayer alignment and prescription drug prices as key areas of focus.

Despite delays in the Serious Illness Population and direct contracting arenas, several CMMI demonstrations that impact hospices continue to move forward. CMS is preparing for the second year of the value-based insurance design demonstration, often called the Medicare Advantage hospice carve-in. The program, which is testing hospice reimbursement through Medicare Advantage, launched Jan. 1. 

The agency has extended its Medicare Care Choices Model (MCCM) demonstration for an additional year. The program is now expected to remain in effect until Dec. 31, 2021, meaning that providers can enroll eligible beneficiaries through June 30, 2021 and provide supportive services through the program’s scheduled end date.

Through the test of its Medicare Care Choices Model, which the agency launched in 2016, CMS has explored the idea of allowing hospice patients to receive concurrent curative care. The model allows participating hospices to provide services that are currently available under the Medicare hospice benefit, but cannot be separately billed under Medicare Parts A, B, and D, while enrollees are also pursuing curative treatments.

As of Nov. 2020, MCCM had reduced the agency’s costs by $26 million.

CMMI was established through the Affordable Care Act. The center has tested close to 50 models since then, with only four of those ultimately becoming a permanent part of Medicare.

“We’ve lost some consensus in the stakeholder community about what we’re trying to achieve and where we’re heading,” Fowler said. “True innovation means failing until we get things right, and it’s just important to learn from what doesn’t work and be transparent about those findings. In my view, we’re at a really critical juncture in the path towards value-based care.”

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