Who’s in charge, them or us?

May 13, 2022

Summary: This JAMA commentary supports doubling down on “value-based care” despite a dismal record of failed demonstrations, and doing so in the context of our dysfunctional multi-payer system. Make no mistake – this is all about enriching corporations that increasingly control our health system. They’re winning, but single payer can still come from behind.

The Center for Medicare and Medicaid Innovation — Toward Value-Based Care
JAMA
May 9, 2022
By John E. McDonough & Eli Y. Adashi

Section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI), replete with $10 billion in guaranteed federal appropriation for 2010 through 2019. Ensconced within the Centers for Medicare & Medicaid Services (CMS), the CMMI was to expand the scope and accelerate the pace of learning with an eye toward hastening the transition from fee-for-service payment models to value-based care.

Since its inception, the CMMI has launched more than 50 model tests involving 28 million patients and more than 528,000 health care practitioners. These efforts at transitioning to value-based care involved Medicare, Medicaid, the Children’s Health Insurance Program, and commercial payers. Of the greater than 50 models tested during CMMI’s first decade, only 6 generated significant savings for Medicare and thereby for taxpayers. Despite this limited record of success and continuing political disagreements regarding Medicaid expansion and other aspects of the ACA, the drive for value-based care remains widely endorsed by both political parties and across most segments of the health care sector.

The first strategic objective of the CMMI, to “drive accountable care,” continues and accelerates this core initiative. CMMI’s new strategy sets an ambitious goal according to which “[A]ll Medicare beneficiaries with Parts A and B will be in a care relationship with accountability for quality and total cost of care by 2030,” as will “the vast majority of Medicaid beneficiaries.”

The second strategic objective of the CMMI, to “advance health equity,” will assume a much higher profile in CMMI’s second decade than it did in its first. Specifically, the CMMI will “require participants to collect and report the demographic data of their beneficiaries.”

The third strategic objective of the CMMI, to “support care innovations,” elevates and operationalizes the incorporation of social determinants of health into the “daily DNA” of the work of the CMMI.

The fourth strategic objective of the CMMI, to “improve access by addressing affordability,” seeks to reduce by 2030 the percentage of beneficiaries who forgo necessary care because of cost.

The fifth and final strategic objective of the CMMI invites opportunities to “partner to achieve health system transformation” by aligning priorities and policies across CMS, and by engaging “payers, purchasers, providers, states, and beneficiaries to improve quality, achieve equitable outcomes, and to reduce health care costs.” Under this strategic objective, all new CMMI models are to make multipayer alignment achievable by 2030.

The value-based care transformation of the US health care system as launched by the ACA is now more than a decade old. Some components of the ACA were the subject of intense and lengthy political conflict. However, the value-based care movement enjoyed near-universal support from federal leaders and key physician, hospital, and other health system organizations despite heretofore mediocre outcomes on both cost and quality. The new CMMI review and planning initiative is a welcome opportunity to renew and reinvigorate this vital national project, especially with the heightened profile of health equity as a core goal.

Comment by: Don McCanne

We now have a decade of “value-based care” experimentation through the Center for Medicare and Medicaid Innovation (CMMI) involving 28 million patients and over a half million health care practitioners. Eighty-eight percent of the VBC models clearly failed and the other twelve percent “successes” were dubious or minimal. Yet the contention is that “value-based care” is widely endorsed and thus the transition should be hastened. The strategic objectives planned over the next decade appear to be intensification of the same questionable policies.

Particularly ominous is the plan to have our entire health care system locked into multi-payer alignment of all new CMMI models by 2030, obviously precluding consideration of a single payer Medicare for All model. That should give the multibillionaires and their private equity enough time to acquire our entire health care delivery system. It will be interesting to see how they implement their value-based care as we pass our health care trillions to the billionaires.

Perhaps we, the people, in an effort to revitalize our movement, should consider adopting a virtual mascot, a pony named Single Payer. We could give it a trial run against a field of ponies representing private equity, corporations, billionaires, industry-supported politicians and deaf government bureaucrats. Since they all operate in secrecy, for this test run we could give our pony the lucky pseudonym Rich Strike (sound on, full screen) … from behind, Rick Strike (Single Payer) wins!

Okay, just a pretend virtual reality, but if they are going to tell us that we want value-based care for all in the form of privatized Direct Contracting/REACH and then force it upon us, can’t we, as the people, force single payer onto the billionaires, bureaucrats, and politicians – for the benefit of all of us? I’d like to ride that virtual pony!