CMMI and the Next Generation of Alternative Payment Models

Neal Shah, Shareholder, Polsinelli, speaks with Scott Strickland, Attorney, Hall Render Killian Heath & Lyman PC, about what the Center for Medicare and Medicaid Innovation (CMMI) has been doing in the health care space. They discuss examples of some of the more prominent CMMI models, the distinction between CMMI models and traditional CMS models, health care industry responses to CMMI models, what the next generation of CMMI models looks like, and the different approaches that CMMI has taken regarding provider payment obligations. Scott co-authored an article for Health Law Connections on this topic. From AHLA’s Regulation, Accreditation, and Payment Practice Group.

Watch this episode: https://www.youtube.com/watch?v=bQysibh0rhY

Read Scott’s Health Law Connections article: https://www.americanhealthlaw.org/content-library/connections-magazine/article/34b68117-81e2-4c7f-9258-245198a69107/CMMI-and-the-Next-Generation-of-Alternative-Paymen 

Learn more about AHLA’s Regulation, Accreditation, and Payment Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/regulation-accreditation-and-payment 

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Transcript

SPEAKER_00 0:04

This episode of AHLA Speaking of Health Law is brought to you by AHLA members and donors like you. For more information, visit AmericanHealthlaw.org.

SPEAKER_01 0:16

Hi everyone. Thanks for joining us. My name is Neil Shaw. I am a healthcare shareholder in Pulsanelli's Chicago office. I'm also the vice chair of the AHLA's regulation, accreditation, and payment practice group. And my guest today is Scott Strickland in Paul Render's Raleigh office and the author of April's HLA Health Law Connections article, CMMI and the Next Generation of Alternative Payment Models. Welcome, Scott. Maybe you could tell us a little bit about yourself.

SPEAKER_02 0:53

Yeah, thanks, Neil. Good to be here. Let me just shout out Raminta Kiziet, my uh colleague here at Hall Render, who co-authored this piece. So I am in her debt for much of the content here. So thank you to her. Like you said, I'm a shareholder with Hall Render in our Raleigh, North Carolina office. I won't go into a long, drawn-out spiel about my health law career, but here's the short version. I've been practicing for almost 20 years now, exclusively in the healthcare space. I would describe myself as a healthcare regulatory and transactional attorney. I've been in the value-based care end of the pool for quite some time, really starting with my tenure in 2010 in the Office of General Counsel for Health and Human Services, which is right around the time that the Affordable Care Act was passed. They hired a whole bunch of folks, program folks in CMS as well as attorneys in the OGC to help roll out the Affordable Care Act. And so that's how I got started down this road of working with folks at CMS, including yourself, Neil, because that's how we know each other from our days when you were my client. But I worked on a number of initiatives while I was there, including the Medicare Shared Savings Program, a number of fraud and abuse program integrity initiatives, including the Star Claw Self-Disclosure Protocol. But most notably, and probably the reason that I ended up writing this article and talking to you today, is that I helped quite a bit with the alternative payment models that were coming out of the Innovation Center at that time, which was new, the new Center for Medicare and Medicaid Innovation Center, which was part of the Affordable Care Act. And we'll get into more of that later in the podcast. But that's how I got started with this. And almost uh 15 years later, here I am working with a whole bunch of folks around the country on um kind of helping them think through uh strategically and operationally how they're going to participate in these models and doing so in a compliant fashion.

SPEAKER_01 3:21

That's great. Yeah, and we're uh very lucky to uh get the benefit of uh all that experience. Um, you know, being being on the client end with you uh in the so many years ago uh definitely uh have been amazing at uh providing guidance on these complicated programs. So maybe we could start here. Um, you know, the whole focus of this discussion is about CMMI or the Innovation Center, as you referenced. Um, maybe you could provide some background. What is CMMI and why should health lawyers or other health law practitioners um be aware of it and be thinking about it in their practice?

SPEAKER_02 3:59

Yeah, um uh great question. So, um first of all, like I said, the the Innovation Center is it's part of CMS. So it is um it's part of that agency. But it was newly created um in 2010 as part of the Affordable Care Act. And so if you go to section, I think 1115A of the Social Security Act, you will see the language establishing the Innovation Center. And so um, and it its purpose, um, the reason it was created is to design, implement, and test new or revised healthcare payment and delivery models that are intended to lower healthcare spending for the Medicare program, Medicaid or CHIP, while maintaining or improving, hopefully, the quality of care provided to those patient populations. So it's essentially like a you know a lab, like a testing lab for CMS, um, where it can quickly spin up and roll out these um models or demonstration programs. Um, and it does not have to go through uh formal rulemaking in order to do that, um, unless the model is a mandatory model, which we'll talk about a little later. But they've got all they're very nimble and they've got a lot of flexibility to um to quickly uh roll out these models, and then um over time, um if the model um has demonstrated that through its performance um that it does either reduce spending or um without uh harming quality of care or that it improves quality of care without increasing spending, then there's authority built into the statute for the Innovation Center to actually roll that out on a larger scale, like nationally, for instance, without having to go back to Congress and getting separate authorization for the program. So basically, CMMI has the authority to expand the scope and duration of a testing model, and that duration can be indefinite if it so chooses. Um, so it has a lot of power and also has some uh ability to waive uh certain programmatic rules or fraud and abuse rules that uh otherwise would apply just in general Medicare and Medicaid programs. So, again, um a lot of the ability to test um innovative um strategies to hopefully lower total cost of care and improve quality of care. And I think on that point, oh sure.

SPEAKER_01 7:03

Sorry to break in, but on that point, please do, yeah. Maybe we could talk a little bit about just where uh practitioners might run into CMMI models. So examples of um some of the larger, more successful, or at least more prominent um CMMI models uh in the past.

SPEAKER_02 7:21

Yeah, absolutely. Um, so if you have ever represented a provider um that is participating in um, well, the REACH ACO program right now, um, that is a CMMI model. Uh prior to that, the NextGen ACO program. Prior to that, the I think the first ACO model that CMMI um sponsored and rolled out was the Pioneer ACO program. All these are companion accountable care organization models that have been running alongside of the Medicare Shared Savings Program ACO model, which was also implemented through the Affordable Care Act, but that was actually implemented through just regular CMS through its notice and comment rulemaking authority. Um other, I think, big um or maybe um bigger models that I think people would have um run into are the BPCI, the bundle payments for care improvement um model, and CJR, um, the joint replacement model. Um both of those are large bundle payment um episode of care models. Um what am I am I missing any, Neil?

SPEAKER_01 8:45

I think those are the very prominent ones, ACOs, bundle payments, you know, and then I guess specialty focused models uh as well. So, but that's great. I mean, I think uh you've illustrated the point, which is just um even if you're not a value-based care lawyer, quote unquote, these models have kind of worked their way into so many different areas of reimbursement, um, both governmental and then taking a lot of the same concepts and spreading them out in the non-governmental space uh as well. Um I wanted to follow up on a point that you made um in talking about that, it kind of drew a distinction between uh the CMMI models and regular CMS. Maybe you could talk about that a little bit. What's the difference? And you know, if you're uh a health lawyer or practitioner working in these models, you know, what are some things to keep in mind um and differences when you're dealing with one of these special CMMI um demonstrations?

SPEAKER_02 9:41

Yeah, um boy, that is a good question. And um here's some things that come immediately to mind. So, first of all, you know, the if you are a provider or an ACO that's participating in the Medicare Shared Savings Program, where do you go to check on the rules of the program? Well, you go to the CFR. Um, as the so um that program is codified in 42 CFR Part 425. And so everything really, of course, there's sub-regulatory guidance as well, but really like the rules of the road are in that part of the CFR. So for a innovation center program, such as the REACH ACO program or the new LEED model, which we'll talk about in a minute, that is really a kind of a continuation of REACH. Um, there are no regs. And so, because they didn't have to go through rule making in order to roll the model out. And so, what there is is a giant participation agreement between CMS and the ACO that contains a lot of the um rules, if you will, of the program. That's the main source of truth. There's also, I think, other documents that are very, very important and instructive in terms of just educating yourselves on how the program works. And um, for instance, like the RFA, the request for applications for a program like this is going to be clocking in at well over 100 pages, and that is like a great source of information. But to answer your question, I mean, for me, one of the main differences is um it's implemented via contract rather than regs. I think another difference along those because of that is that CMMI has, and I'm sure you've seen this Neil in your practice, but you know, CMMI just has more flexibility to make changes midstream during the program because they don't have to go through rulemaking. And so that can be uh, and they've done that quite a bit with REACH, for instance, where every year there'll be some changes that they're announcing through really amendments to that participation agreement, and they don't have to go through rulemaking, and so they can do that a little quicker. I I think also, and really just informed, maybe speculation on my part, but just from what I've seen out in the with representing different clients and talking to different stakeholders in the healthcare space, you know, it's it's a little bit easier to lobby CMMI um for changes in these programs because, first of all, it's easier for them to make changes midstream. Second of all, I think they're um I think sometimes a little bit um more receptive to making provider-friendly changes that mean that they will have a critical mass of providers in order to get meaningful data and actually test the program so they can determine whether or not it makes sense or is authorized under the statute to actually expand it. So um uh that to me is one of the maybe the primary difference between the two.

SPEAKER_01 13:10

And to tease that out a little bit, I mean, not having to go through rulemaking is uh huge, in part because you don't have to worry about notice of comments. So the long you know time period associated with uh collecting information, evaluating it, responding to in some cases thousands of comments. Um you can kind of set a lot of that aside. And you don't have kind of a specific statutory language that guides what you're supposed to be doing as an agency. Instead, you know, as you said, you have much more flexibility to say what's working, what's not working, and and let's kind of implement changes um on a purely contractual basis, um, which is often very uh one-sided, it's not really negotiated, right? It's it's a that's right.

SPEAKER_02 13:54

Those are yeah, and those are take it or leave it contracts, you don't send them a bunch of red lines, or if you do, that's kind of shouting into the void, you're not going to get anything back really.

SPEAKER_01 14:06

On that contractual point, maybe we could talk about that too, because that is something that I've seen is a huge difference for these demonstration models as compared to some of the more permanent Medicare uh reimbursement methodologies, um, is that there's a lot of downstream contractual relationships. Um, and and some of the fundamental kind of payment models um are really structured by multiple types of private entities um in these voluntary contractual relationships, as opposed to kind of a payer um, you know, re governmental reimbursement type of relationship that is more typical of the Medicare program, for example.

SPEAKER_02 14:48

Yeah, I I think that's right. And and just you know, for the attorneys out there listening, I think um uh I'm sure folks that are in the space um are realizing that as if you're representing providers, um, hospitals, physician groups, et cetera, you're likely encountering these programs not through a direct relationship with CMS, but through a direct relationship with an intermediary entity, such as an accountable care organization, which might be operated by a health system, but it may also be private equity backed. Um and so you've got an agreement to participate in the program, but you're participating through the ACO or the risk-bearing entity. Um if you are even in the bundle payment programs, you know, if you're a downstream provider, if you're not really an anchor hospital, but you are involved in the care provided to the Medicare beneficiary during the episode of care, you're likely engaging through a sharing arrangement with the provider. Again, you don't have a direct relationship with CMS, but you've got um what looks like a gain sharing arrangement with the provider in order to share hopefully some of the savings that accrue to managing that patient through the episode of care. So there are, you know, if you're attorney in the space, you're reviewing a number of uh those types of participation agreements. Um, you're thinking through issues that span from the fraud and abuse area, you've got data sharing slash HIPAA issues, you've got just general contractual issues, you know, in terms of um what are we going to do if there's a dispute about how much savings I should have received, or um, you know, termination issues with respect to if and when a provider can get out of that relationship in order to pursue maybe a better opportunity with another uh value-based care enabler. So they're a whole host of both traditional legal issues and very in the weeds healthcare, Medicare specific issues that I think attorneys representing these entities that are participating will need to work through. And that's true, um, Neil, like you said, even you know, all this is bleeding over, has already like kind of bled over into the Medicare vantage space and commercial space. And so a lot of these value-based care arrangements that were originally tested through CMS's authority under the Innovation Center are popping up in different contexts. And so providers are encountering them in different areas as well.

SPEAKER_01 17:46

Yeah, absolutely. And you know, so it's it's interesting. We've we've seen a lot of these concepts proliferating out there. I I think one big example is attribution, for example, in the ACO world, where you know, how do you decide which Medicare patients belong to a particular ACO in terms of the ACO having responsibility for managing or being accountable for their health status and spending? A lot of those concepts have now moved to Medicare Advantage, the MIPS program, you know, other other parts of um the overall healthcare payment landscape. Um I'm wondering, you know, CMMI, it's been around for 15 years at this point, it is um influential in so many different areas of the healthcare system. What has the response been so far? You know, what what kinds of um positive and negative responses, you know, have been out there in the provider and and regulated community as a whole.

SPEAKER_02 18:46

Ooh, um that there's a lot, there's a lot to unpack there. I would say that um, you know, it's interesting. Maybe it's interesting because where I'm coming from, usually I'm interacting with folks that are um very much pro-value-based care. Um that's that's why they're talking to me. Yeah. Um I I think that big picture, I think um there's been a slow and steady uptick in I think the um appetite for and actually participation in these value-based care models, like over time. If you're looking at it just from 2010 to where we are now, I think that is clear. I think there have been along the way um maybe two main gripes from the provider and policy community. And maybe number one is that um, you know, from a policy perspective, this hasn't moved the needle as much as maybe some folks would like in terms of really making a meaningful dent in um savings to the Medicare program. Um, I think there have been some demonstrable improvements in the quality of care and coordination of care. But I think probably in, you know, if you were to go back in time and talk to folks like right around the time that um the ACA was passed in those first few years, they'd probably be thinking that in 2026 um we'd have maybe uh maybe found a few silver bullets here that we haven't yet. And perhaps that's just partly because it's been very easy for providers to really operate in both worlds. Um and I say easy because CMMI and CMS have allowed that. And so there it's not like they're gaming the system, it's just the way that the system is operating right now and is designed. But um, you know, you're you're never really operating just solely in a value-based care world. You've got a lot of your health care um spend revenue that is still tied up in fee for service, like even in these models. And so um I think maybe that's one criticism of um not only CMMI, but just the value-based care initiative, writ large in general, is that it's not moving quite as quickly as uh we would like to get us away from the fee for service world. And then I think the other thing for providers is just um just in general there it's it's hard over time, and I think CMMI is is and CMS um in both avenues is trying in good faith tried to address this, but um it's hard over time to succeed financially in these programs, um, even when you're doing well. They're rebasing the benchmark. You're competing against like a prior version, a better version of maybe yourself. And so they're making some programmatic changes there. Certainly, like in lead, like with the 10-year time horizon and no rebasing of the benchmark. I think that they are attempting to address some of the criticisms from the provider community with respect to like whether or not long term it's really financially viable for the providers to participate in these models and really commit all the time, money, capital to succeed over the long haul.

SPEAKER_01 22:50

Yeah, absolutely. I mean, there's always pros and cons. Um, I guess the other thing I would say that I see that I think is keeps pulling providers in is just that you know, there's not always um a lot of new sources of funds in the healthcare system. I mean, they they tend to be fairly limited and well understood. And the new model always provides an option, especially if you are a high performer or uh a provider who you know has an edge in in particular types of quality or or management of costs. This is a way to potentially get access to additional funds and additional kinds of resources um based on being a high performer in those areas. And so that can be hard to find sometimes in our healthcare system right now. So it's absolutely yeah, I think that's right.

SPEAKER_02 23:41

And I think that they are again through LEED is one example. There are other examples from CMMI over the last few years where they are doing, I think, more um, they're focused more on getting some non-traditional, um, like rural independent providers, providers without a lot of capital that were, I think, staying on the sidelines. Um, they are trying to get those folks into these models through some um promises of upfront money, um, some upfront capital, uh, which I think is starting to move the needle a little bit. But I'd still say that there um is probably a in order for organizations to I think really succeed in these initiatives right now, they've got to have a fairly sophisticated internal um operation, um, both like clinically and analytically, to determine which of these models makes the most sense financially and how once they're in, um, how are they gonna, what levers are they gonna be able to pull in order to um do the best they can to actually achieve savings? And that to me, right now, is still separating the haves from the have nots is that kind of internal institutional um knowledge.

SPEAKER_01 25:07

Well, and that's a great segue. So, you know, your article and Romento's article as well was about the next generation, right? Forward looking, you know, what what happens from here? Um, and so I'd love if you could talk about that a little bit. What what does the next generation look like and and kind of um what can providers in this space uh you know look forward to um in CMMI's new kind of direction?

SPEAKER_02 25:35

Yeah, um well we'll see. We'll see if if if they really will look forward to it. Yeah. Um some so I think I've just let me just hit, I'm gonna hit just like on the broad themes that CMMI has actually said over the last year that where you know this is these are their targets or these are their north stars as they develop these models. Um, and so they just taking them um at their own words, they're trying to drive choice and competition. So they are trying to expand the universe of what's possible. And so we're seeing a whole lot of different ways to plug in and participate in these models. And so, as you know, Neil, there have been like a flurry of activity in the last really year or year and a half, and so that's one thing I um that strikes me is that there will just be more opportunities for different types of providers to participate in these models, and it won't always be through just you know an accountable care organization taking risk for like uh an entire like global risk on a patient population. Like we're there's there are a lot of more targeted models for specialists, um, for technology providers, and so I think that's that's number one, um, just a wider variety of the types of ways that a provider or um healthcare entity can engage with these models. Um, number two, I think they have signaled an interest to um promote evidence-based prevention, uh, which goes hand in hand, I think, with some of the policy initiatives coming out of just um the regular CMS. Um, so we're certainly starting to see those are um there's an increased focus in almost every model that they roll out, that they're embedding in the model some type of um prevention uh focused care. Um, one example is is balance, um, which um is a voluntary model that is focused on reducing cost barriers, but also like pairing, basically um promoting medication access and nutrition and lifestyle supports for beneficiaries. So um I think we're we'll see more of that. Um, I think the two or three things that are most interesting for me. Um, number one, I think, and we've seen this in the wiser model. Um, I think there are gonna be more models which uh build in prior authorization to um the model that's being tested. And so again, I'm not sure providers are gonna be looking forward to that, but it's certainly something to keep in mind that the the prior authorization tools that um really where Medicare advantage payers have led the way, I think are are going to start popping up in traditional Medicare. And I think CMMI is gonna lead the way in testing those on behalf of the original Medicare program. Um, I also think that it's clear uh team is one example. Um it's clear that mandatory models are very much in the mix for this particular iteration of the innovation center for a number of reasons. I mean, first of all, like mandatory participation, I think over time it addresses a concern about selection bias. And so now CMMI doesn't have to worry about when they're actually looking at the data, um, this self-selection problem. They know that, well, all the providers in this area or all the providers practicing this specialty were in. I think it's a better representation of a broader cross-section of providers and patients. I think it makes it easier for them to actually review the data and prove up whether or not the model is appropriate for expansion. Um, so I think we'll see more of that. And then finally, I think the it's clear that this version of CMMI, I think, wants to push as many folks as possible in these models to take on two-sided risk. In other words, to be at risk for downside losses, in addition to being able to recoup savings. And so they are trying as best they can to get providers and again, not just the ACOs, but on down to the provider level, to the actual MPI, TIN level, to take on to have some sort of skin in the game. And I think they just think frankly that that means that there's a better likelihood they're going to achieve meaningful cost savings.

SPEAKER_01 30:56

And just to clarify for folks who may not have run into this concept, downside risk essentially means that if the costs of the patient population that you're serving are uh higher than expected based on all sorts of adjustments that CMS applies, um, there is a payment obligation incurred. And a big question is where that payment obligation sits. Right. Could you talk about that a little bit? Just kind of the different approaches that CMI uh has taken to that problem.

SPEAKER_02 31:27

Absolutely. Yeah, and thank you. I like the you the way you frame that. So it's just big picture in and let's just focus on the ACO programs. So right now in the Medicare shared savings program, there there are tracks, and you can uh you, the ACO, the providers that are participating in the ACO, you can remain in a upside-only um track for at least five years. Um and so, and what that means is that nobody, the ACO, none of the providers, is exposed to um downside risk or paying back CMS if the total cost of care for the attributed population is above the benchmark. Now, in LEAD, the LEAD model, which is the new ACO model that CMMI is testing, that will start January 1 of 2027, and the deadline for the RF, the applications was yesterday. Um, so in this model, it's everyone that participates, all the ACOs have to take on some level of risk. So there is no one-side-only path. Everyone is going to be in a two-sided risk path. Now, what that has traditionally meant is that the ACO carries the risk. And although it's certainly permissible for the ACO to pass that risk along to the participating providers, practically speaking, as I know you're well aware, Neil, like just it's hard to get providers that are participating in these value-based models to agree that they are going to be on the hook to either ACO or CMS to actually pay back a portion of those losses. So what CMS has said, or excuse me, what CMMI has said in the lead model for the first time is that there's a requirement that the ACO, or there's a prohibition against the ACO carrying 100% of that downside risk. And so there's a requirement that the ACO pass along at least 1% of the potential risk of loss to the participating providers in the ACO. And what that is going to look like practically, I think that's still up in the air, still not a lot from CMI in terms of like how it expects that relationship to look. It's going to be, I think, up to folks like me and you, Neil, to help our clients uh navigate what a compliant arrangement is going to look like that both satisfies CMS's requirement, but also just doesn't totally blow the relationship up between the provider and the ACO. So more to come on that. But I think that to me was a like a canary in a coal mine, if you will. I think that's a big signal for me that CMMI is thinking long term that these value-based enablers, the conveners, the ACOs, these middlemen, if you will, between the provider and the program can't carry the risk all by themselves forever. That it's got to make its way down to the provider level in some fashion in order to better ensure that there's meaningful movement on decreasing total cost of care.

SPEAKER_01 35:04

Well, that's very interesting. And just a quick point related to the conversation about sort of your role, my role, health lawyers' role as a as a whole on this. It's very interesting kind of how much change these value-based care models, especially the ones pushed by CMMI, have kind of um triggered revisions or new issues, you know, in multiple areas of law. We've talked about fraud and abuse and compliance. Antitrust is an issue that often has to be worked out. Um state insurance regulation may be an issue that needs to be worked out. Corporate practice and medicine may be an issue that needs to get worked out. So these tend to have a lot of different um implications for the entities that jump into them and often require a fair amount of sort of creative thinking, strategic thinking uh on the part of legal counsel and and healthcare advisors of all of these entities.

SPEAKER_02 36:02

So absolutely. I I would say um just following up quickly on that point, that when I'm thinking about um how best to advise folks that are attorneys that are in the space and and how to help them help their clients, I mean, for me, it's uh attorney I used to work with would say that um that we we healthcare lawyers that we're all in some way, shape, or form reimbursement lawyers. And I think that's very much the case um with respect to helping clients um navigate these models and also negotiate contracts, agreements with respect to these models is that you really you do need a pretty solid understanding of how payment works in these models and how the payment to your client, the provider, is going to change who's going to be making the payment, is there capitation involved? Um, are we operating under a bundle payment approach? Um and a lot of that, like understanding how the model works, how the different payment and delivery structures work, I think will inform what are the most important issues in the contract to negotiate in terms of you mentioned one earlier, Neil, in terms of like beneficiary attribution, like who's going to be attributed to me, um, to our provider? Uh, how are savings determined? Um, when's the reconciliation going to occur? When am I going to receive savings? How am I going to know that the savings are correct? What do I do if I think they're incorrect? Like all that. So I would just, my advice would be make sure that you get a little bit in the weeds with these different sub-regulatory guidance documents that are coming out from CMMI because they'll be they're almost like an instruction manual for how to approach the negotiation when you are assisting the client.

SPEAKER_01 38:09

Well, I know we're getting close to time here. Um, one last question, I guess. Um, you mentioned a couple of different models uh in this kind of new group uh that that CMMI has released. You mentioned lead, uh team, wiser. Are there any others that are particularly interesting or that you're kind of keeping an eye on uh or that you think are maybe emblematic of uh the revised approach that CMMI is taking now?

SPEAKER_02 38:37

Oh, I think um if I had to mention one more, um I think the um the ASNM model um is probably worth noting just really quick because I think one of the things that the Innovation Center, uh, you know, another I think theme of more recent models that have come out is their focus on specialty care and just acknowledging that frankly, like a lot of the cost um is wrapped up in specialist care and is not always controlled by the traditional primary care providers, which have been the traditional focus of a lot of these models. And so ASM illustrates, I think, their new focus on specialty care. It's also a mandatory model, but just very briefly, specialists that are required to participate in this model are benchmarked against their peers with respect to certain performance measures with related to quality and cost of care and coordinating care. And then based on how they do with respect to that peer comparison, CMS is going to adjust their future Medicare Part B uh payments, like to the specialists, either going to stay the same, go up, or go down based on their performance. And so that to me is um one worth watching because it is specifically focused on the specialists, and it's this isn't like there's no indirect participation here. I mean, there's like a meaningful impact on their direct Part B um payments. And so I think that's one to watch because this is something that frankly they could spin this up just like CJRX, um, which is now uh a national um initiative that started out as a CMMI model. This could very well end up as a national model through notice and comment rulemaking after CMMI does the work necessary to determine that it meets the statutory criteria.

SPEAKER_01 40:52

And we should note that specialty care has been a longstanding focus or issue for all of these value-based care programs, which historically have focused on total cost of care um with more of a primary care focus. Um, specialty care has been a tough nut to crack, and so that we'll see if this is uh that this can move the needle. So um, well, thank you so much, Scott, for uh all of your wisdom and experience uh in this space. You know, um our uh audience, you know, I think uh got a lot of great information through this kind of conversation. So appreciate uh your sharing your time uh here and appreciate everyone for listening. So thanks.

SPEAKER_02 41:34

Oh, I appreciate it. Thank you, Neil, for giving me the opportunity and um was my pleasure. So thank you.

SPEAKER_00 41:45

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