The CMMI Policy Arc on Syam Adusumilli

The Great CMMI Reset

Sun, 15 Mar 2026 00:00:00 +0000

On March 12, 2025, in one of the new administration’s first concrete actions in federal health policy, the Center for Medicare and Medicaid Innovation announced that it would end four alternative payment models before their originally scheduled termination dates. The announcement was terse. CMS had conducted a “data-driven review” of its model portfolio. Some models would conclude as scheduled. Others would stop by December 31, 2025. The agency estimated the changes would produce $750 million in savings, without specifying its methodology.

Summary: The Great CMMI Reset

Sun, 15 Mar 2026 00:00:00 +0000

On March 12, 2025, CMS announced the early termination of four CMMI alternative payment models: Primary Care First, Making Care Primary, the ESRD Treatment Choices Model, and the Maryland Total Cost of Care Model. Two additional models, the Medicare $2 Drug List and the Accelerating Clinical Evidence initiative, were halted before implementation. CMS estimated the changes would produce $750 million in savings, without publishing its methodology. The action came less than two months after the Biden administration had terminated the VBID model in December 2024, the only active CMMI model operating inside Medicare Advantage. Together, these decisions cleared the FFS innovation portfolio in a way that was atypical in both speed and scope.

The New CMMI Playbook

Sun, 15 Mar 2026 00:00:00 +0000

Two months after terminating four payment models, CMMI released the formal architecture of what replaces them. On May 13, 2025, CMS Administrator Mehmet Oz and CMMI Director Abe Sutton hosted a webinar and published a white paper, frequently asked questions document, and updated strategy page titled “CMS Innovation Center Strategy to Make America Healthy Again.” The materials established a three-pillar framework that will govern every new model CMMI designs, every existing model it evaluates for continuation, and every certification decision it makes for the rest of this administration’s tenure.

Summary: The New CMMI Playbook

Sun, 15 Mar 2026 00:00:00 +0000

On May 13, 2025, CMS Administrator Mehmet Oz and CMMI Director Abe Sutton published the formal architecture that replaces the models terminated in March. The white paper and accompanying materials, titled “CMS Innovation Center Strategy to Make America Healthy Again,” established a three-pillar framework anchored in prevention, patient empowerment, and competition. The foundational principle underlying all three pillars, stated in every document CMS published that day, is taxpayer protection. That language carries statutory weight: Section 1115A of the Social Security Act requires the Secretary to certify that any model expanded beyond testing either reduces net program spending or improves quality without increasing spending. The May 2025 refresh made that certification requirement the operative design standard for all CMMI activity, not only the threshold for post-evaluation expansion decisions.

WISeR

Sun, 15 Mar 2026 00:00:00 +0000

For sixty years, one of the defining structural distinctions between Original Medicare and Medicare Advantage was prior authorization. MA plans used it routinely: 99 percent of MA enrollees are in plans requiring PA for some services, and in 2023 MA plans made 1.8 prior authorization determinations per enrolled beneficiary. Traditional Medicare did not. In FY2023, the existing Medicare FFS prior authorization programs reviewed 3.1 million claims, representing less than one percent of the 1.2 billion total Part A and B claims processed that year. The asymmetry was so pronounced that it served as a foundational argument for choosing Original Medicare over MA — the argument that a beneficiary’s doctor, not an insurance plan, would make treatment decisions without a middleman.

Summary: WISeR

Sun, 15 Mar 2026 00:00:00 +0000

For sixty years, one of the defining structural distinctions between Original Medicare and Medicare Advantage was prior authorization. MA plans used it routinely: 99 percent of MA enrollees are in plans requiring PA for some services, generating 1.8 PA determinations per enrolled beneficiary in 2023. Traditional Medicare’s existing PA programs reviewed 3.1 million claims in FY2023, less than one percent of the 1.2 billion Part A and B claims processed. On January 1, 2026, that asymmetry narrowed when the Wasteful and Inappropriate Service Reduction Model introduced AI-powered prior authorization and prepayment medical review into Original Medicare fee-for-service for the first time at material scale.

ACCESS

Sun, 15 Mar 2026 00:00:00 +0000

Medicare’s payment architecture has not changed structurally for digital health since the program was created in 1965. Fee-for-service reimburses defined activities: a visit, a procedure, a device implanted, a test ordered. It does not reimburse outcomes. It does not reimburse continuous monitoring between visits. It does not reimburse the software that aggregates wearable data into a clinical dashboard, or the asynchronous care management workflow that a digital therapeutics company runs to keep a hypertensive patient on medication. These are exactly the things that health technology companies have spent fifteen years proving can improve chronic disease outcomes at scale — and they sit entirely outside the reimbursement boundary that Medicare draws.

Summary: ACCESS

Sun, 15 Mar 2026 00:00:00 +0000

Medicare’s fee-for-service architecture reimburses defined activities: a visit, a procedure, a test ordered. It does not reimburse outcomes. It does not reimburse continuous monitoring between visits, the software aggregating wearable data into clinical dashboards, or the asynchronous care management workflows that digital therapeutics companies run to keep hypertensive patients on medication. For the digital health sector, this reimbursement gap has been the central strategic problem since the first wave of venture capital arrived in consumer health technology. The ACCESS model, announced December 4, 2025, with a July 2026 launch cohort, is the first systematic attempt by CMS to address that gap at scale.

BALANCE

Sun, 15 Mar 2026 00:00:00 +0000

Medicare has been prohibited by statute from covering weight loss drugs since 2003. The Medicare Prescription Drug, Improvement, and Modernization Act excluded agents used for weight loss from the definition of a covered Part D drug, a restriction rooted in the fen-phen safety scandal of the late 1990s and the congressional judgment that weight management medications were elective rather than medically necessary. For two decades, that exclusion held. More than 40 percent of Medicare beneficiaries age 60 and older meet the clinical definition of obesity, and none of them could access the most effective pharmacological treatments for it through their Medicare drug benefit.

Summary: BALANCE

Sun, 15 Mar 2026 00:00:00 +0000

Medicare has been prohibited by statute from covering weight loss drugs since 2003, when the Medicare Prescription Drug, Improvement, and Modernization Act excluded agents used for weight loss from the Part D benefit definition. More than 40 percent of Medicare beneficiaries age 60 and older meet the clinical definition of obesity, and none can access the most effective pharmacological treatments through their Medicare drug benefit. The Biden administration attempted to resolve this through a November 2024 proposed rule reinterpreting the statutory exclusion; the Trump administration declined to finalize it, citing CBO’s estimate that full coverage would increase federal spending by $35.5 billion over nine years. The BALANCE model, announced December 23, 2025, takes a different path: using CMMI’s Section 1115A demonstration authority to waive the statutory exclusion for participating plans and states without changing the law.

MAHA ELEVATE

Sun, 15 Mar 2026 00:00:00 +0000

In 2022, approximately 45 percent of Medicare beneficiaries had four or more chronic conditions. Those beneficiaries accounted for nearly 90 percent of total Medicare spending. The arithmetic of chronic disease in the Medicare population is not complicated: a system that spends the overwhelming majority of its resources treating downstream complications of conditions rooted in nutrition, physical inactivity, sleep disruption, and chronic stress is a system structurally misaligned with its own spending drivers. Medicare has never lacked awareness of this problem. What it has lacked is a payment mechanism for addressing the upstream behaviors. The fee schedule pays for office visits, procedures, imaging, and pharmaceuticals. It does not pay for the structured lifestyle interventions that the clinical evidence increasingly identifies as the most effective first-line treatment for the conditions consuming the budget.

Summary: MAHA ELEVATE

Sun, 15 Mar 2026 00:00:00 +0000

In 2022, approximately 45 percent of Medicare beneficiaries had four or more chronic conditions. Those beneficiaries accounted for nearly 90 percent of total Medicare spending. The fee schedule pays for office visits, procedures, imaging, and pharmaceuticals, but not for the structured lifestyle interventions that clinical evidence identifies as effective first-line treatment for the conditions consuming the budget. Medicare has never lacked awareness of this misalignment. What it has lacked is a payment mechanism for addressing the upstream behaviors. MAHA ELEVATE, announced December 11, 2025, is CMMI’s attempt to build the evidence base for that mechanism from inside Medicare’s own population.

LEAD and ASM

Sun, 15 Mar 2026 00:00:00 +0000

Accountable care organizations have been the most durable structural reform in Medicare since the ACA created them in 2010. By Performance Year 2024, 476 MSSP ACOs served 11.2 million beneficiaries, generated $2.4 billion in net Medicare savings, and paid out $4.1 billion in shared savings to participating providers. Two-thirds of those ACOs now carry downside risk. Another 103 ACOs operated under ACO REACH, covering roughly 2.5 million additional beneficiaries. Taken together, more than half of all Original Medicare FFS beneficiaries are now attributed to an ACO.

Summary: LEAD and ASM

Sun, 15 Mar 2026 00:00:00 +0000

Accountable care organizations are the most durable structural reform in Medicare since the ACA created them in 2010. By Performance Year 2024, 476 MSSP ACOs served 11.2 million beneficiaries, generated $2.4 billion in net Medicare savings, and paid out $4.1 billion in shared savings. Two-thirds of those ACOs now carry downside risk. Another 103 ACOs operated under ACO REACH, covering roughly 2.5 million additional beneficiaries. More than half of all Original Medicare FFS beneficiaries are now attributed to an ACO. That trajectory has been strong in aggregate but uneven in composition: ACOs have been built disproportionately by large health systems, multispecialty groups, and well-capitalized enablement companies. Small practices, rural providers, independent physicians, and specialists have remained on the periphery. LEAD and ASM are designed to change that composition from opposite directions.

AHEAD and Geo AHEAD

Sun, 15 Mar 2026 00:00:00 +0000

Every CMMI model discussed in this series so far assigns accountability to an organization: an ACO assumes risk for attributed beneficiaries, a specialist absorbs payment adjustments for episode performance, a manufacturer negotiates pricing for a drug category. AHEAD and its Geo AHEAD component do something different. They assign accountability to a place. A state agrees to manage total cost of care across all payers for its entire population. Hospitals accept global budgets that replace fee-for-service claims with prospective biweekly payments. And in Geo AHEAD, entities that may not be providers at all, health plans, digital health companies, technology firms, bid competitively to take financial responsibility for Medicare FFS beneficiaries who live in a geographic region, regardless of where those beneficiaries currently receive care.

Summary: AHEAD and Geo AHEAD

Sun, 15 Mar 2026 00:00:00 +0000

Every other CMMI model in the 2025 portfolio assigns accountability to an organization: an ACO, a specialist, a manufacturer. AHEAD and its Geo AHEAD component assign accountability to a place. A state agrees to manage total cost of care across all payers. Hospitals accept global budgets replacing fee-for-service claims with prospective biweekly payments. And in Geo AHEAD, entities that may not be providers at all, including health plans, digital health companies, and technology firms, bid competitively to take financial responsibility for Medicare FFS beneficiaries who live in a geographic region, regardless of where those beneficiaries currently receive care.

GLOBE and GUARD

Sun, 15 Mar 2026 00:00:00 +0000

Americans pay, on average, three times what residents of other developed countries pay for the same prescription drugs. Medicare Part B drug spending has grown faster than drug spending across all other payers since 2008. Part D drug spending in 2024 constituted approximately 30 percent of all U.S. drug expenditure. These disparities have driven two decades of policy proposals to tie U.S. drug prices to international benchmarks, none of which have been implemented at scale. The first Trump administration tried in 2020 through the Most Favored Nation Model, an interim final rule that would have pegged Medicare Part B drug reimbursement to international reference prices. Three federal courts enjoined it within days. The Biden administration rescinded it.

Summary: GLOBE and GUARD

Sun, 15 Mar 2026 00:00:00 +0000

Americans pay, on average, three times what residents of other developed countries pay for the same prescription drugs. Two decades of policy proposals to tie U.S. drug prices to international benchmarks have produced no implementation at scale. The first Trump administration tried in 2020 through the Most Favored Nation Model, an interim final rule that three federal courts enjoined within days on procedural grounds. The second Trump administration is trying again through CMMI’s Section 1115A demonstration authority and the formal notice-and-comment rulemaking process the first attempt skipped. On December 19, 2025, CMS proposed two mandatory models: GLOBE for Medicare Part B and GUARD for Medicare Part D. Together with the voluntary GENEROUS model for Medicaid announced six weeks earlier, they constitute the most ambitious attempt to implement international reference pricing across all three major federal health programs simultaneously.

The 2025 CMMI Scorecard

Sun, 15 Mar 2026 00:00:00 +0000

Between March and December 2025, the CMS Innovation Center cancelled four models, halted two before they launched, announced nine new models, and redesigned one active model. That pace of activity, concentrated in ten months, is without precedent in CMMI’s fifteen-year history. The result is a fundamentally different Innovation Center than the one that entered 2025, operating under a different strategic framework, targeting different policy objectives, and testing a different theory of how Medicare payment reform generates savings.

Summary: The 2025 CMMI Scorecard

Sun, 15 Mar 2026 00:00:00 +0000

Between March and December 2025, the CMS Innovation Center cancelled four models, halted two before they launched, announced nine new models, and redesigned one active model. That pace of activity, concentrated in ten months, is without precedent in CMMI’s fifteen-year history. The result is a fundamentally different Innovation Center operating under a different strategic framework, targeting different policy objectives, and testing a different theory of how Medicare payment reform generates savings.