CMS Roadmap to 2025

Recently, I was part of an industry panel focusing on factors that would impact the near-term future of CMS. I was asked to discuss the impact of healthcare policies on the CMS roadmap up to 2025, a little more than 5 years away. The first point I addressed in my response was a remark around the fact that there will be three major elections within that time period, including two presidential elections. As the old saying goes, “Elections have consequences,” and that is never truer than in healthcare policy. Each political party often presents very different proposals for how to best solve the nation’s healthcare challenges.

Even within parties, we see major policy differences between approaches – for example, the Biden plan compared to the Sanders plan, or on a lesser scale, how Alex Azar currently runs HHS compared to how Tom Price planned to run it. Clearly, forecasting is never an exact science, but I came up with ten key policy-issues that will greatly impact CMS in 2025 and beyond, regardless of which party or individual happens to be in the White House at that time.

All these issues currently impact CMS to some extent and will only grow in influence over the next five years. Space constraints only allow me to address several of them in this blog, with the remaining items to follow in future blog posts. These issues are:

1. Federal government’s role in national healthcare
2. Medicare payment coverage
3. Continued evolution of value- payments and care
4. Future of Federal Medicaid funding and policies
5. Evolvement of Program Integrity away from fee-for-service
6. Medicare Advantage Risk adjustments solely based on encounter data
7. Continuing challenges of privacy and security
8. Health IT-interoperability and patient engagement
9. Controlling medical costs
10. Increasing industry consolidation

The first four sections are covered in greater detail below:

1. The extent of the Federal Government’s role in national healthcare – This issue drives many other policy decisions and could have huge impacts on Marketplace, traditional Medicare, Medicare Advantage, Part D, and Medicaid. Even without a single-payer healthcare system, both Federal and CMS roles in healthcare have grown tremendously over the last fifteen years. One major question currently without a definitive answer pertains to what role CMS will play if “Medicare for All,” or some type of single-payer or government expansion, becomes law. Readers might recall when the Affordable Care Act was originally passed, the Obama Administration created a separate HHS agency to implement Marketplace. That ill-advised effort was quickly abandoned, however a “Medicare for All” effort would be much larger and encompassing. Should CMS be tasked with running that type of program?
2. Medicare Payment Coverage – What Medicare covers in its payment policies helps drive the entire healthcare industry. In the coming years, coverage decisions will come under more pressure as major changes in healthcare delivery and technology occur. For example, telehealth is continuing to grow and expand as the technology to support it improves. Also, as public health in rural communities continues to face challenges with the opioid epidemic and the closing of rural hospitals, the need for telehealth to support healthcare in remote areas will continue to grow. Improvements in personal devices and the expansion of 5G technology will also create pressure on payers to support their use in healthcare delivery and monitoring. Further policy areas with a potential impact on Medicare are as follows:
   • Some in Congress are pushing to make traditional Medicare coverage more aligned with today’s industry benefit offerings, to include dental and vision care or even long-term care.
   • The push towards personalized medicine and designer drugs holds much promise, but many of the new drugs, tests, devices, and procedures are very expensive. How CMS chooses to pay (if at all) for some of these innovations potentially exposes a new risk, in that it may increase health disparities between the haves and the have-nots.

3. Continued evolution of value-payments and care – This area has received bipartisan support over the years, but exactly how quickly and completely it will occur is still an open question. Another concern exists regarding what types of value programs will become most prevalent. The Obama Administration, for example, promoted mandatory bundled payments for certain types of procedures, however this current Administration does not require as much. Other potential impact points include:
   • A proposed revision of the Stark Law and the anti-kickback statute that was released recently could make it easier for providers to coordinate care without fear of violating anti-kickback regulations.
   • An increasing role of social determinants in value criteria could create additional complexity.
   • Moving towards value-based outcomes for drugs could have a major impact on newer high-priced drugs to treat certain cancers and other conditions.
4. Future of Federal Medicaid funding and policies – Medicaid is a highly-political area which has seen major changes over the past ten years: first with Medicaid expansion, and then with some of the work and other requirements that the current Administration and several states have tried to push through. The role of Medicaid, program eligibility requirements, and how it is funded will continue to be a major part of the CMS mission for the foreseeable future.

These policy areas are not the only ones that will have major impacts on CMS operations in the coming years. In my next blog post, I will discuss the others that I have listed earlier. All these items hold the potential to create changes in healthcare that will challenge the ability of the CMS leaders and staff to manage their various programs.[social_warfare]