New CMMI Director Liz Fowler: US at ‘Really Critical Juncture’ on Path to Value-Based Care

The U.S. health care system has hit a defining moment in its shift toward value-based care, with the major decision in 2021 being an aggressive acceleration or cautious slowdown of the nation’s portfolio of alternative payment models.

Liz Fowler, the new head of the Center for Medicare and Medicaid Innovation (CMMI), has been thinking about this value-based care “crossroads” since joining the agency not quite two months ago.

“We want the CMS Innovation Center model tests to work, to lower costs, improve quality of patient care and better align payment systems to promote patient-centered practices,” Fowler said Tuesday during a National Association of ACOs (NAACOS) virtual event. “But we also need to be honest about the nature of innovation, that not everything is going to be a home run. Some things will work, others won’t.”


NAACOS is a Washington, D.C.-based advocacy group that represents hundreds of accountable care organizations (ACOs) across the country.

Since its formation following the Affordable Care Act’s passage, CMMI has developed more than four dozen alternative payment models, with only four becoming a permanent part of Medicare. The mandatory nine-state Home Health Value-Based Purchasing (HHVBP) Model is one of the innovation hub’s most successful demonstrations, government data suggests.

CMMI has rolled out a handful of its alternative payment models over the past couple of years alone. Prominent examples include its somewhat controversial direct-contracting initiative, which currently features the “Global” and “Professional” options with different degrees of risk for participants.


Another direct-contracting concept known as the “Geographic Direct Contracting Model” was originally scheduled to begin on Jan. 1 of next year, but the new Biden administration CMMI has opted to put it under review for an undefined period of the time.

NAACOS is among the groups to raise concerns about direct contracting.

“In my view, we’re at a really critical juncture in the path toward value-based care,” Fowler said. “And this is my perspective, having worked on these issues for a while. I feel like over the last 10 years since the center was established, we’ve lost some consensus in the stakeholder community about what we’re trying to achieve.”

Fowler isn’t the only health care expert to critically question the CMS Innovation Center’s ongoing projects. The Medicare Payment Advisory Commission (MedPAC), for instance, has discussed how CMMI needs a more harmonized portfolio of alternative payment models with fewer, more strategic designs.

Former Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma has similarly talked about a need for recalibration.

“The center stands in need of a course correction in model design and portfolio selection, if value-based care is to advance,” Verma said in October.

CMMI and CMS haven’t just pumped the brakes on the Geographic Direct Contracting Model. Earlier in April, policymakers announced they were shutting down a second round of applications for the Global and Professional options.

So far, 53 organizations have been approved to take part in Year 1 of the two directing-contracting options. Of those, 39 are participating in the Global option and 14 in the Professional option.

In March, CMS also revealed plans to delay implementation of the Primary Care First Serious Illness Population payment model, with no new start date in sight.

On her end, Fowler took a “two steps forward, one step back” stance on those moves.

“Innovation and health system transformation is not easy, and it is an iterative process,” she said at the NAACOS event. “At CMMI, we want our alternative care models to position participants for success. Sometimes that means speeding up when there’s an opportunity, and sometimes it means taking a beat to ensure that a forthcoming model can realistically deliver on what’s intended — and that it’s the strongest option based on our evidence and data.”

Prior to her post at CMMI, Fowler was executive vice president of programs at The Commonwealth Fund and vice president for global health policy at Johnson & Johnson. She was chief health counsel to Sen. Max Baucus (D-Mont.), chair of the Senate Finance Committee, from 2008 to 2010, playing a critical role in developing the Senate’s version of the Affordable Care Act.

While CMMI is carefully evaluating all of the new alternative payment models emerging, the agency is not any less dedicated to advancing its value-based care mission, Fowler emphasized.

“We’re taking a look at the portfolio,” she said. “In the words of a previous CMMI leader, it’s really like looking at your retirement portfolio and, every once in a while, [realizing] it needs to be rebalanced.”

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