The 27th Risk Adjustment Forum opened in Orlando with a look at where federal payment policy is headed, and the speaker came straight from the source. Eliot Fishman, Director of the Policy and Programs Group at the CMS Innovation Center (CMMI), delivered the opening address on CMMI’s priorities heading into 2027 and walked attendees through the models shaping provider payment, Medicaid, care at home and drug pricing.
Most of the models he covered sit in original Medicare and Medicaid, and the reason they matter to Medicare Advantage came up early: the payment rules CMS tests in fee-for-service end up in the provider contracts your plan negotiates.
How a pilot becomes national policy
Fishman opened with the Innovation Center’s core job, which is to design and test new payment and care delivery models and then scale the ones worth keeping. Some models reach national scale through certification by the HHS Secretary and some through Congress, and he pointed to bundled payment for lower extremity joint replacement in original Medicare and the $35 monthly insulin copay cap as two examples of tested models now written into national policy.
He also noted the agenda reflects the current administration’s priorities alongside a good deal of continuity, since career staff carry much of the work from one administration to the next. For plans planning past 2027, this means today’s models are a reasonable preview of tomorrow’s rules.
Why original Medicare payment changes reach your plan
Original Medicare sets the baseline for pricing across the health care system, and Medicare Advantage organizations and commercial payers lean on its rates and methods when they negotiate provider contracts. Fishman argued the deepest flaws in physician payment, particularly how specialists get paid, have to be fixed inside original Medicare first, and the models he walked through show where CMMI is pushing.
- Primary care capitation. Physician Fee Schedule proposals and requests for information keep moving fee-for-service primary care toward capitated payment, paired with ACO structures.
- Mandatory bundles. The Transforming Episode Accountability Model (TEAM) now runs across a large share of the country and ties hospitals to spending across the stay and the post-acute period.
- LEAD. The Long-term Enhanced ACO Design model succeeds ACO REACH and, for the first time, adds tracks for specialty capitation under an ACO, through full global risk and primary care partial capitation options.
- Mandatory specialty accountability. CMMI is piloting a mandatory MIPS Value Pathways model for select conditions and specialties, with real upside and downside risk to answer the long-standing complaint from specialists about MIPS measures and weak financial stakes.
- ACCESS. This technology-supported chronic care model pays participating coalitions of technology firms and clinical providers for outcomes instead of individual digital encounters, using remote patient monitoring, wearables and longitudinal care plans.
Fishman explained the ACCESS design in terms many specialists will recognize, since fee-for-service rewards a gastroenterologist for a colonoscopy and pays little or nothing for patient messages, non-procedural consults or care coordination. Because payment follows outcomes, the technology inside the model is free to change without CMS rewriting the payment method each time.
“We want to be paying for outcomes rather than activities. That has been the holy grail as long as I’ve been in health policy.”
States, aging at home and drug prices
The rest of the address covered three more priority areas, each with clear ties to plans serving Medicaid and dual eligible members.
- State and multi-payer models. The AHEAD model builds on Maryland’s Total Cost of Care model with statewide cost accountability, hospital global budgets and primary care accountability across payers. Models still in pre-implementation target maternal health, high and rising risk children, and integrated physical and behavioral health, with two-sided risk outside traditional managed care.
- Aging adults and care at home. The GUIDE dementia model now operates nationally, and Fishman said CMS is weighing ways to open PACE to more people who are not dually eligible. LEAD also brings redesigned benchmarks meant to draw in higher-spending providers who sat out ACO REACH and the Shared Savings Program, plus a healthy aging strategy with beneficiary engagement incentives and benefit enhancements.
- Drug pricing. The GENEROUS model applies most favored nation pricing to state Medicaid programs, with nearly every state taking part through its Medicaid agency.
The questions from the floor
The Q&A turned to data. One attendee asked whether CMMI will move past data-sharing mandates such as TEFCA, FHIR and prior authorization reform to score the completeness and clinical usefulness of the data plans and providers exchange. Fishman confirmed FHIR capabilities are already built into several new models and described the push toward electronic data extraction and digital quality measurement, along with the balance CMMI has to strike between demanding advanced interoperability and keeping on-ramps open for providers without strong health IT. He added CMS Administrator Dr. Oz has made interoperability and digital measurement a personal priority.
A second question came from Maryland, where an attendee described data still stuck in silos across the state’s total cost of care infrastructure. Fishman gave a direct answer on where the real barriers to exchange sit, and on how CMS and ONC plan to keep pressure on data sharing across state-based models, and the exchange set the tone for a forum built around how plans get accurate data from the point of care into their risk and quality programs.
Digital quality measurement and FHIR readiness move to the center of the agenda at The 16th Annual HEDIS® & Quality Improvement Summit, Nov. 3-5 in Baltimore, where quality leaders work through the transition to fully digital HEDIS® with NCQA in the room.