Abe Sutton Signals New Directions for CMMI
Abe Sutton, the new director of the Center for Medicare and Medicaid Innovation, has begun to set a new course for the CMS Innovation Center. In a discussion this week with Mark McClellan, M.D., Ph.D., director of the Duke-Margolis Institute for Health Policy, Sutton stressed the importance of downside risk and standard design features across alternative payment models.
Before assuming the leadership role at CMMI in January of 2025, Sutton was a principal at Rubicon Founders, where he co-founded two health service companies; Honest Health, which focuses on enabling primary care physicians, and Evergreen Nephrology, which focuses on enabling nephrologists. From 2017 to 2019, he served at the National Economic Council, Domestic Policy Council and Department of Health and Human Services.
In a wide-ranging discussion with McClellan, Sutton said the work at CMMI will in some ways continue the path followed over the past several years but also will branch out into some new areas. He said tertiary prevention is an area where they want to invest.
Sutton recalled that when he was supporting providers as they participated in alternative payment models, it was often unclear what counts as a saving. “Let’s say you as a participant are claiming shared savings. That doesn't necessarily mean that the office, the actuary, is going to score a model as a saver, so the disconnect built in for how benchmarks are set versus how the actuary would measure things led to a disappointing track record in terms of savings for some models,” he said. “Obviously there are learnings that we take from that. There are lessons that inform future model design that, I think, lead us to be better prepared now.”
One of those lessons is that downside risk really matters for changing behavior, he said. “People respond differently when there's downside risk. So in order to ensure that there's a pathway for certification through cost savings on our models, I think downside risk, where we have risk-based models, will really make a difference.”
He also hopes to make models simpler to administer by having some standard design features span across models. "There were obviously some similarities between the REACH ACO model and the CKCC model,” he said. “Having common infrastructure used across our models can make a difference just in administrating these models and ensuring that there's a path for us to scale them in a sustainable manner going forward.”
Another area he mentioned that could help us set up models to be savers is thinking about low-value care and unnecessary utilization that could be harmful for folks. “Seeing how we could incentivize reductions in that unnecessary care and help guide people to care that's right for them, I think will make a difference on cost trajectory in the long run,” Sutton said. “All of the pillars really build on prevention, avoiding costly disease, on empowering patients, on helping people make the healthcare decision that is right for them, and on choice and competition, on really having the market conditions that will drive down costs over time.”
McClellan asked about the potential role of technology in enabling healthcare transformation.
“If we think about the potential for generative AI and what can be done with technology, there is a potential for technology to massively increase our supply of healthcare in this country, if you think about how physicians and providers can be supported in the care for their patients, how people could be empowered with new access to information, so that our existing healthcare resources could be stretched more effectively,” Sutton responded.
But he added that there’s also potential for massive inflationary impact from some of these new technologies. “I think about the use of AI scribes and how they help systems capture more services. Now those services were delivered always, but now that there's more accuracy in the billing, so it's not fraud, it's not mal-intentioned. There is going to be more payment flowing out in order to reimburse for those services that are now accurately reflected. We're going to need to be very intentional in grappling with this and ensuring that we encourage the development of technology in a manner that increases supply and lowers costs.”
Sutton said he views tech as an accelerator of CMS’ broader efforts. Greater data collection, analysis and analytic capabilities, and the scalability of technologies are some things he believes they can make a difference on. “If I think about the over 1,000 FDA-cleared AI/ML-enabled medical devices that are now in use, what's the reimbursement pathway there? And can we make it more predictable for folks who are making investments in the next 1,000 AI and ML-enabled medical devices, so that they know that there's a reimbursement structure out there? “
He said he believes they need to capitalize on the potential to invest in some targeted reforms to encourage the adoption of AI technologies. “I get very animated around around that, because I think it's something that could be really transformational in the current moment in how we approach technology in healthcare.”
