Medicare Part D, Part V: What’s Next for CMMI?

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Tune into the fifth and final episode of the Avalere Health Essential Voice miniseries focused on Medicare Part D. In this segment, our experts discuss the Center for Medicare & Medicaid Innovation (CMMI) and its strategic direction for the coming year, particularly as it relates to the Part D program.
“If the administration is not successful in advancing some of their core drug pricing priorities through legislation, we may begin to see CMMI step to the forefront and take on some of those issues.” Ryan Urgo, Managing Director, Policy


Sarah Butler , Head, Client Solutions, Marketing & Operations

Sarah Butler specializes in evidence-based medicine, value-based contracting, and strategy development.

Ryan Urgo , Managing Director, Policy

Ryan Urgo provides strategic advice to drug manufacturers, health plans, and advocacy groups to help them navigate the health policy environment and understand the impact of legislative and regulatory policies on their business goals.

Guest Speaker
Neil Lund , Senior Advisor, Avalere Health
Neil Lund brings more than 30 years’ worth of actuarial and formulary management experience to the firm; he works with a range of life sciences and health plan clients on issues tied to market access, patient access, and product positioning.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.


Sarah: Hello and welcome back to another episode of our Avalere Health Essential Voice Series, focused on Medicare Part D. My name is Sarah Butler and I’mthe Head of Client Solutions Marketing and Operations here at Avalere.

I’m joined today by two of my colleagues, Ryan Urgo, who is a Managing Director in our policy team, Neil Lund, who is a Senior Advisor in our market access team. And today’s discussion is going to focus on CMMI and where we can anticipate some activity in the coming year, particularly as it relates to the Part D program.  

So with that, I’m going to jump right in. Ryan, let’s start with you. So we have some new leadership at CMMI, which is really exciting. But so far, things have been pretty quiet. So just broadly speaking, where do we expect CMMI to be headed in terms of its strategic direction?  

Ryan: Thanks, Sarah. So things have been quiet, but I wouldn’t take that as a lack of future activity that we can expect to see. I do think that if we look at recent comments that Director Fowler has made about the strategic direction for CMMI and just the broad strategic review of existing models, it does point to a way forward for the Innovation Center broadly.  

We know that they have talked about really improving the focus and attention on underserved communities, and really using the demonstration authority that they have to improve health equity goals for the administration.  

We also know that the agency has talked about, or rather the Innovation Center has talked about streamlining the sheer volume of models that move through the center. And just focusing more on those models that address broad population- based health goals and improvements in value- based care.  

Sarah: Great. So recognizing those goals, Neil, what are your thoughts on some of the potential ideas that the agency could pursue?  

Neil:  Thank you, Sarah. Director Fowler has made some comments that indicates that she and the agency are questioning whether their primary goal is lowering drug costs.  

In fact, their kind of planting the seeds about broader structural change. And this could be important because it suggests new ideas, more creative models, a real structural change in the approach to the models.  

Sarah:  So Neil, do you anticipate that some of the initiatives implemented under CMMI during the prior administration will continue? And if so, which ones do you think are most likely to continue?  

Neil:  The prior administration had a heavy, if not exclusive focus on lowering drug costs. So, I do anticipate some changes here. However, I strongly believe the Senior Savings Model will continue.  

Because while it is heavily focused on lowering drug costs, it also contains some models around structural change for the program. So, that’s one that I really expect to continue.  

Sarah: Great. So you mentioned that the prior administration really focused on drug pricing. Where do you anticipate that this new leadership will really look to make its market at CMMI?  

Neil: That’s a great question and one that if we look at what’s happening in healthcare today, what a lot of the discussions outside of Washington are, that gives us some indication.  

We’re seeing a lot of discussion about social determinants of health, we’re seeing a lot of discussions around health equity. And also, how do you serve underserved populations? How do you address their issues?  

The first two, health equity and social determinants of health are areas that are not well- defined, not well- understood. So in those areas, we could definitely see the agency looking to focus the discussions and definitions as to what we’re going to try to attack in those two areas.  

Underserved populations, of course, is another issue that we have to look at certain structural changes such as prescribing patterns, how do we improve adherence, things like that for the underserved populations.  

A very different approach than the first two.  

Sarah: Yeah, great. Thank you. That’s very helpful. So a few moments ago, Neil, you mentioned the Senior Savings Model. We know that this model has gotten some scrutiny previously. Ryan, can you give us an update here?  

Ryan:  Sure. Well, I agree with Neil, that I think the Senior Savings Model is definitely one to keep an eye on and something that the new leadership is likely to continue. The Senior Savings Model was interesting ’cause it was a bit of a departure from how most models have been structured in the past, where the agreements were two- way in nature.  

Meaning it was the agency partnering with provider groups or the agency partnering with ACOs, or the agency partnering with health plans. With senior savings, we saw a three- Way agreement, the agency drug manufacturers and health plans.  

And they were using that agreement to address drug pricing, which was in some ways, a bit of a departure from the traditional mandate of the demonstration center to focus on lowering federal spending and or improvement in quality.  

So I think the Senior Savings Model pushes the envelope a little bit into showing that the center can be used to advance policy goals. And I do think it also points to a potential way forward for stakeholders, as we look towards the coming years.  

Neil: I would like to add two additional comments to what Ryan has said. The first is, the Senior Savings Model actually modified the benefit in the deductible and in the gap phase, which means that structural innovation can take place at CMMI.

So, that’s one reason why I think it will continue. The other thing though that I’d like to add is for manufacturers. Even if you’re not involved in insulins, it’s very important to watch a program like this and understand what’s going on.  

Because you can start to understand the intent of the administration and what could happen from a structural standpoint.  

Sarah:Yeah. Thank you, Neil, and thank you, Ryan. Ryan, one more followup question for you though here. Some of the objectivesthat you mentioned of the Senior Savings Model, isn’t Congress trying to tackle some of these issues through legislation right now?

Ryan: Indeed. The reconciliation effort has slowed a little bit, as Congress has turned its eye towards the debt ceiling. But I think that that pace will continue to pick back up. But I think what’s most important is what doesn’t happen legislatively, as it relates to CMMI.

Meaning if the administration is not successful in advancing some of their core drug pricing priorities through legislation, that’s when I think we may begin to see CMMI step into the forefront and take on some of those issues.  

One area we know the administration has really prioritized is value, and incorporating value into drug pricing in some fashion. Because the Congress is somewhat limited in what they can do legislatively through budget reconciliation, it’s reasonable to think that they will try to pursue some of these goals through the Innovation Center.  

Likewise, on the manufacturer side, if there are affordability priorities and goals that don’t make it into the legislative compromise to Congress, then I think that the CMMI can also be used for that purpose.  

Again, I would point to the Senior Savings Model as an example where affordability on a particular issue could be addressed through the demonstration. So, I think that the key point is that the Innovation Center can be used by both sides of the drug pricing debate right now to advance priorities.  And I think there are opportunities and risks with that that we need to just be clear right about going forward.  

Sarah: Thank you. Neil, any closing comments on this?  

Neil:  Yes, I have one in particular, and that is, I do not expect Congress to attack anything on social determinants of health. It’s an area that is not well- defined today, and is best served through something like CMMI.  

Sarah: Well, I’m afraid that’s all we have time for today. Thank you, Ryan and Neil, for joining me today. And thank you for all of you for tuning into the Avalere Health Essential Voice. Please stay tuned for more episodes. And if you’d like to learn more, you can visit us at Thanks, everyone.  

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